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-773-8461 Email: dss.ebtstateoffice state.sd.us SELECT ONE: This is the first time I have completed an NEMT Payment Authorization form. I have already completed an NEMT Payment Authorization form and want to make changes to the following: Name Change Address Change Telephone Change Change the way I receive my NEMT payments (Direct Deposit or NEMT Payment Card) NOTE: You must complete a separate payment Authorization form for each program in which you receive payments. The information provided o.

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