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 Hospital Beds
• 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
• Home Care Transportation Certification
• 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 
• 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

• 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 Hospital Beds
• 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 New or Existing Group
• Provider Enrollment Application Instructions - Add Member to New or 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
• Home Care Transportation Certification

Rhode Island Medicaid is implementing an electronic process for enrolling and updating Trading Partners.  Due to this transition, we will be unable to accept Trading Partner enrollment applications or add/change forms after Tuesday, September 9, 2014. Forms received after this date will be returned.

Beginning Wednesday, September 17, applicants may access the electronic enrollment process by visiting http://www.eohhs.ri.gov/ProvidersPartners/HealthcarePortal.aspx.

All existing Trading Partners are required to register in the Healthcare Portal.  Please refer to the current issue of the Provider Update.  Additional resources are found on the Healthcare Portal page. 

• 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 Hospital Beds
• 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  
  • Dental Claim Form Sample - Medicaid only  
  • Dental Claim Form Sample - Other Insurance  
• 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