Get Sd Dss-os-950 2015-2026

Filling out the SD DSS-OS-950 form is essential for reimbursement of medical transportation costs under the Title XIX Medicaid program. This guide provides clear, step-by-step instructions to ensure that users complete the form accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Click the ‘Get Form’ button to access the SD DSS-OS-950 form and open it in your chosen online editor.
2. In Section 1, provide the Medicaid recipient information. Include the name, date of birth, address, Medicaid number, and phone number.
3. Move to Section 2, which requires payment information. Indicate where the reimbursement should be sent, including the mailing address and phone number. Confirm if you have completed the NEMT Payment Authorization form.
4. Proceed to Section 3 to disclose any financial assistance received. Check ‘YES’ or ‘NO,’ and if applicable, provide the name of the organization, its mailing address, type of assistance, and amount received.
5. In Section 4, fill out the trip information section. Specify the cities traveling from and to, the departure and return dates, the mode of transportation, and any lodging details for both the recipient and the driver/escort.
6. Section 5 requires a signature and date from the recipient, parent, or guardian, certifying the accuracy of the information provided.
7. Finally, complete Section 6 with the medical provider's information, ensuring they sign and date the form as well.
8. Once all sections are filled out, check for completeness. You can save changes, download, print, or share the form as needed.

Complete your SD DSS-OS-950 form online today to ensure timely reimbursement for your medical transportation.