SD Department of Human Services

I attest that I have the authorization to provide the information on behalf of afore mentioned entity and the information is true and accurate to the best of my knowledge. I understand and agree that misrepresentation or omission of pertinent information regarding the entity and/or service(s) provided will result in the exclusion of the entity from the Dakota at Home Resource Directory database. Furthermore, it is acknowledged and understood that participation in the on-line Dakota at Home Resource Directory operated by the Department of Human Services does not constitute an endorsement of the entity by the South Dakota Department of Human Services.

*Name of Person completing Request: Title:

* Entity:
Entity Type:(Non-profit, goverment, for profit)
Description (Describe the primary services provided):
Main Phone:	TDD/TTY No:
Main Website:	Main Email:
Days / Hours of Operation:
Primary Contact:			Title:
Phone:	Cell:	Email:
Address:
City:		State:	Zip:
Secondary Contact:			Title:
Phone:	Cell:	Email:
Address:
City:		State:	Zip:
Program/Site Location: (Please complete a separate form with applicable information for each program/site).
Street Address:				Suite:
City:		State:	Zip:
Mailing Address:
City:		State:	Zip:
Phone:		Fax:
Entity has been in business for at least six (6) months? YesNo			Number of staff persons employed:
Bilingual staff available: YesNo			Languages supported:
Physical location is wheelchair accessible: YesNo		Explain:
Eligibility Requirements: Who is eligible for your services? Are services restricted to certain populations based on age, gender, income, family status, etc.?
Payment Source (check all that apply) Free Medicaid Free will donation accepted Self Payment Medicare Veterans Administration Insurance Accepted Sliding Scale other:__________________________
Cities served:
Counties served:
Zip Codes served:
Ages served:

* Completion of this form is not a guarantee of inclusion in the on-line Dakota at Home Resource Directory.

I attest that I have the authorization to provide the information on behalf of afore mentioned entity and the information is true and accurate to the best of my knowledge. I understand and agree that misrepresentation or omission of pertinent information regarding the entity and/or service(s) provided will result in the exclusion of the entity from the Dakota at Home Resource Directory database. Furthermore, it is acknowledged and understood that participation in the on-line Dakota at Home Resource Directory operated by the Department of Human Services does not constitute an endorsement of the entity by the South Dakota Department of Human Services. *Name of Person completing Request: Title: