Forms & Applications

Medicaid

• Addendum I - the Glossary
• Adjustment Form 
• Adjustment Form Instructions
• Authorization for Direct Deposit 
• Certificate of Medical Necessity
• Certificate of Medical Necessity for Enteral Nutrition
• Certificate of Medical Necessity for Pressure Reducing Support Surfaces
• Certificate of Need for Hearing Aid
• CMS-1500 Claim Form
• CMS-1500 Claim Form Instructions
• Consent Form for Sterilization Procedures
• Consent Form for Sterilization Procedures - Spanish   
• Dental Claim Form
• Dental Claim Form Instructions
• Electronic Funds Transfer
• Hospital Room and Board Revenue Codes
• Hysterectomy Consent Form
• Local Education Agency (LEA) Provider Linkage Form
• MDS MOD Home Care Agency Form
• NDC Attachment Form
• NDC Attachment Form Instructions
• Out of State Questionnaire
• Pharmacy Claim Form
• Pharmacy Claim Form Instructions
• Point of Service Application
• Prior Authorization Submission Process
• Prior Authorization Form
• Prior Authorization Form Interactive Instructions
• Provider Change of Information Form
• Provider Agreement
• Provider Enrollment Application - Individual
• Provider Enrollment Application - Group
• Provider Enrollment Application - Add Members to Existing Group
• Provider Enrollment Application Instructions - Individual
• Provider Enrollment Application Instructions - Group
• Provider Enrollment Application Instructions - Add Members to Existing Group
• Recoupment Form
• Recoupment Form Instructions
• Refund Log
• Request for Disposable Gloves
• Request for Prior Authorization for DME-Children Only
• Request for Prior Authorization for Home Modification and/or Special Medical Equipment/Rehab Equipment
• RIte Share Enrollment Application - Individuals
• Rite Share Enrollment Application - Groups
• Rite Share Enrollment Application - Add Members to Existing Group
• Third Party Liability (TPL) Information Card 
• Trading Partner Agreement
• Trading Partner Agreement Add/Change Form
• UB-04 Claim Form
• UB-04 Claim Form Instructions
• Waiver Claim Form
• Waiver Claim Form Instructions
• W-9 Form and Instructions

Provider Enrollment Application and Related Forms

• Provider Enrollment Application - Individual Providers
• Provider Enrollment Application Instructions - Individual Providers
• Provider Enrollment Application - Group Providers
• Provider Enrollment Application Instructions - Group Providers
• Provider Enrollment Application - Add Member to Existing Group
• Provider Enrollment Application Instructions - Add Member to Existing Group
• Provider Agreement 
• Addendum I - the Glossary
• RI Medical Assistance Disclosures
• Additional Federally Required Disclosures 
• Exclusion Letter
• W-9 Form and Instructions 
• Out of State Questionnaire
• Hospital Room and Board Revenue Codes
• RIte Share Enrollment Application - Individual
• RIte Share Enrollment Application - Group
• RIte Share Enrollment Application - Add Member to Existing Group
• Local Education Agency (LEA) Provider Form

Business Process Forms

• Trading Partner Agreement
• Trading Partner Agreement Add/Change Form
• Point of Service Application
• Authorization for Direct Deposit
• Provider Change of Information Form
• Third Party Liability (TPL) Form 

Prior Authorization Forms

• Prior Authorization Submission Process
• Prior Authorization Form
• Prior Authorization Form Interactive Instructions
• MDS MOD Home Care Agency Form
• Certificate of Medical Necessity
• Certificate of Medical Necessity for Enteral Nutrition
• Certificate of Medical Necessity Instructions
• Certificate of Need for Hearing Aid
• Certificate of Medical Necessity for Oxygen
• Request for Prior Authorization for Home Modification and/or Special Medical Equipment/Rehab Equipment
• Request for Prior Authorization for DME-children only
• Rental Property Agreement - Authorization for Home Modifications/Special Equipment
• Core and Preventive Home and Community Based Services Form 
• Request for Disposable Gloves
• Consent Form for Sterilization Procedures
• Consent Form for Sterilization Procedures - Spanish 
• Hysterectomy Consent Form

A comprehensive listing of BHDDH departmental rules and regulations can be found at the Rhode Island Office of the Secretary of State's website.

• Secretary of State Website: BHDDH Final Rules and Regulations

Proposed BHDDH regulations can also be found on this website at:

• Secretary of State Website: BHDDH Proposed Rules and Regulations

RI Works

RI Works Red Book
The RI Works Red Book is a resource that was developed to assist RI Works parents find appropriate work preparation activities as part of their Employment Plans.  The Red Book is arranged in three (3) sections:

1. Contracted Providers
2. Pre-Certified Vendors/Vocational Education
3. DHS In-House Service Providers

For a description of each, see Introduction to the Red Book.

Contracted Providers

• Contracted Provider - by Name and by Type 
• Contracted Providers - List

Pre-Certified Vendors/Vocational Education

• Pre-Certified Vendors/Vocational Education - by Name and by Type 
• Pre-Certified Vendors/Vocational Education - List

DHS In-House Providers

• Office of Rehabilitation Services (ORS), Vocational Rehabilitation Services to RIW Clients
• RI Department of Labor & Training, Rhode Island Works

Child Care Assistance Program

For information on becoming a CCAP Approved Provider, please call the Office of Child Care at (401) 462-6877.

New information coming soon!

• Provider Enrollment Application - Individual Providers
• Provider Enrollment Application Instructions - Individual Providers
• Provider Enrollment Application - Group Providers
• Provider Enrollment Application Instructions - Group Providers
• Provider Enrollment Application - Add Member to Existing Group
• Provider Enrollment Application Instructions - Add Member to Existing Group
• Provider Agreement 
• Addendum I - the Glossary
• RI Medical Assistance Disclosures
• Additional Federally Required Disclosures 
• Exclusion Letter
• W-9 Form and Instructions 
• Out of State Questionnaire
• Hospital Room and Board Revenue Codes
• RIte Share Enrollment Application - Individual
• RIte Share Enrollment Application - Group
• RIte Share Enrollment Application - Add Member to Existing Group
• Local Education Agency (LEA) Provider Form

• Trading Partner Agreement
• Trading Partner Agreement Add/Change Form
• Point of Service Application
• Authorization for Direct Deposit
• Provider Change of Information Form
• Third Party Liability (TPL) Form 

• Prior Authorization Submission Process
• Prior Authorization Form
• Prior Authorization Form Interactive Instructions
• MDS MOD Home Care Agency Form
• Certificate of Medical Necessity
• Certificate of Medical Necessity Instructions
• Certificate of Medical Necessity for Enteral Nutrition
• Certificate of Need for Hearing Aid
• Certificate of Medical Necessity for Oxygen
• Certificate of Medical Necessity for Pressure Reducing Support Surfaces
• Request for Prior Authorization for Home Modification and/or Special Medical Equipment/Rehab Equipment
• Request for Prior Authorization for DME-children only
• Rental Property Agreement - Authorization for Home Modifications/Special Equipment
• Core and Preventive Home and Community Based Services Form
• Request for Disposable Gloves
• Consent Form for Sterilization Procedures 
• Consent Form for Sterilization Procedures - Spanish 
• Hysterectomy Consent Form

• CMS-1500 Claim Form
  • CMS-1500 Claim Form Instructions  
• Dental Claim Form
  • Dental Claim Form Instructions
• NDC Attachment Form
  • NDC Attachment Form Instructions
• Pharmacy Claim Form
  • Pharmacy Claim Form Instructions
• UB-04 Claim Form
  • UB-04 Claim Form Instructions
• Waiver Claim Form
  • Waiver Claim Form Instructions
• Adjustment Form 
  • Adjustment Form Instructions 
• Recoupment Form  
  • Recoupment Form Instructions 
• Refund Log