RIte Share Providers

Completing this form is not necessary if the provider currently has a Rhode Island Medicaid number.  Individual providers, new groups and new providers joining an established group should submit documentation according to the requirements outlined in each link below:

RIte Share - Individual Provider Enrollment Form   

RIte Share - New Group Provider Enrollment Form  

RIte Share - New Provider Joining an Established Group 

In addition to the application form above, please submit:

1. A copy of the NPI letter you received from CMS that contains your NPI and Taxonomy 
   numbers
2. A valid copy of your license to practice
3. Provider Agreement    (Name must match page 1 of application and W-9; original
   signature is required) 
4. Addendum I- the Glossary    (Original signature is required) 
5. RI Medicaid Disclosure  
6. Additional Federally Required Disclosures    (If Necessary) 
7. Exclusion Letter    (Original Signature Required) 
8. W-9 and instructions    (Name must match page 1 of the application) 

Additional Forms

Authorization for Direct Deposit    (Mandatory)