South Dakota Medicaid's PA-104 requests prior authorization of private duty nursing or extended home health aide services. A physician meets it because the request must be sent with a current plan of care signed by a physician. The form sets out the weekly RN, LPN and aide hours requested and asks about the adult caretakers' work and school schedules outside the home.
The home health or private duty nursing agency completes the form as the accepting or servicing provider, with the physician listed as referring provider. The physician signs the plan of care that accompanies it.
Download the current version from the source each time; forms change without notice.
Prior Authorization Request Form: Private Duty Nursing & Extended Home Health Services
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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A current plan of care signed by a physician. The form itself carries the procedure codes, quantity, dates of service, diagnosis codes, weekly hours by staff type and the caretakers' schedules, while the plan of care documents the physician's orders for the nursing or aide services.
The number of adult caretakers in the home, the hours each is employed or at school outside the home per week, and, when there is more than one, the hours all are away at the same time. Hours include typical travel time but exclude hours the child is in school, and there is space for notes on the guardian's schedule.