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)

 

 

 

 

 

 

PDF All PDFs require the free Adobe Reader.

 

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