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Form DSS-NEMT-964 Medicaid Non-emergency Medical Travel Authorization for the Use or Disclosure of Protected Health Information - South Dakota
What Is Form DSS-NEMT-964?
This is a legal form that was released by the South Dakota Department of Social Services - a government authority operating within South Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is Form DSS-NEMT-964?
A: Form DSS-NEMT-964 is the Medicaid Non-emergency Medical Travel Authorization for the Use or Disclosure of Protected Health Information in South Dakota.
Q: What is the purpose of Form DSS-NEMT-964?
A: The purpose of Form DSS-NEMT-964 is to authorize the use or disclosure of protected health information for non-emergency medical travel under Medicaid in South Dakota.
Q: Who needs to fill out Form DSS-NEMT-964?
A: Form DSS-NEMT-964 needs to be filled out by Medicaid beneficiaries who require non-emergency medical travel.
Q: What information is required on Form DSS-NEMT-964?
A: Form DSS-NEMT-964 requires the Medicaid beneficiary's personal information, medical provider's information, travel details, and authorization for the use or disclosure of protected health information.
Q: Is Form DSS-NEMT-964 specific to South Dakota?
A: Yes, Form DSS-NEMT-964 is specific to South Dakota and is used for Medicaid non-emergency medical travel authorization in the state.
Form Details:
- Released on April 1, 2021;
- The latest edition provided by the South Dakota Department of Social Services;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a printable version of Form DSS-NEMT-964 by clicking the link below or browse more documents and templates provided by the South Dakota Department of Social Services.
Download Form DSS-NEMT-964 Medicaid Non-emergency Medical Travel Authorization for the Use or Disclosure of Protected Health Information - South Dakota
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