Forms & Applications
You will find Medicaid Provider forms and applications below.
All documents are in pdf format
Medicaid
- Addendum I - The Glossary
- Adjustment Form
- Adjustment Form Instructions
- Certificate of Medical Necessity
- Certificate of Medical Necessity Instructions
- Certificate of Medical Necessity for Biomarker Testing
- Certificate of Medical Necessity for Disposable Gloves
- Certificate of Medical Necessity for Enteral Nutrition and Total Parenteral Nutrition
- Certificate of Medical Necessity for External Infusion Pump
- Certificate of Medical Necessity for Hospital Beds
- Certificate of Medical Necessity for Oxygen
- Certificate of Medical Necessity for Pressure Reducing Support Surfaces
- Certificate of Need for Hearing Aid
- Certificate of Medical Necessity for Diabetic Shoes
- 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
- Face-to-Face Encounter Documentation Form
- General Application for Enhanced Home Health Reimbursement
- HCBS Application for Shift Differential and Client Acuity Payment
- Home Care Attestation Form - One-Time Supplemental Payment
- Home Care FFS Provider Agreement
- Home Care Reporting Home Health Agency One Time Supplemental Payment
- Home Care Transportation Certification
- Home Health Agencies Behavioral Health Rate Enhancement - Policy and Procedures and Reporting Template
- SFY 22 Home Health Agencies Shift Differential Increase - Policy and Procedures and Reporting Template
- SFY 23 Home Health Agencies Shift Differential Increase - Policy and Procedures and Reporting Template
- SFY 24 Home Health Agencies Shift Differential Increase - Policy and Procedures and Reporting Template
- Home Modifications, Special Medical Equipment and Assistive Devices Services Form (GW-SF)
- Homeowner Property Agreement - Authorization for Home Modifications/Special Equipment (GW-HM)
- Home Stabilization Referral Form
- Hysterectomy Acknowledgement Form
- Hysterectomy Payment Form
- Local Education Agency (LEA) Provider Linkage Form
- MDS Home Care Agency Form
- NF Licensed Bed Policy Intent Memo
- NF Nursing Facility Change in Licensed Bed Capacity Request Application
- NDC Attachment Form
- NDC Attachment Form Instructions
- Nursing Home Wage Pass-through Reporting Template
- Prior Authorization Submission Process
- Prior Authorization Form
- Prior Authorization Form - Chiropractor Providers Only
- Prior Authorization Form Instructions
- Provider Change of Information Form
- Provider Agreement
- Provider Enrollment Application - Add Members to Existing Group
- Provider Enrollment Application Instructions - Add Members to Existing Group
- Recoupment Form
- Recoupment Form Instructions
- Refund Log
- Rental Property Agreement - Authorization for Home Modifications/Special Equipment (GW-RA)
- Request for Prior Authorization for DME-Children Only
- Request for Prior Authorization for Home Modification and/or Special Medical Equipment/Rehab Equipment (GW-EM1)
- Severe Malocclusion Treatment Request Form
- 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 - 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 Medicaid Disclosures
- Additional Federally Required Disclosures
- Exclusion Letter
- W-9 Form and Instructions
- Local Education Agency (LEA) Provider Form
- Home Care Transportation Certification
Business Process Forms
- Electronic Funds Transfer
- Provider Change of Information Form
- Third Party Liability (TPL) Information Card
Prior Authorization Forms
- Prior Authorization Submission Process
- Prior Authorization Form
- Prior Authorization Form Instructions
- MDS Home Care Agency Form
- Certificate of Medical Necessity
- Certificate of Medical Necessity Instructions
- Certificate of Medical Necessity for Biomarker Testing
- Certificate of Medical Necessity for Disposable Gloves
- Certificate of Medical Necessity for Enteral Nutrition and Total Parenteral Nutrition
- Certificate of Medical Necessity for External Infusion Pump
- 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
- Certificate of Medical Necessity for Diabetic Shoes
- Director of Nurses Statement for Hearing Aids form
- Face-to-Face Encounter Documentation Form
- Home Modifications, Special Medical Equipment and Assistive Devices Services Form (GW-SF)
- Homeowner Property Agreement - Authorization for Home Modifications/Special Equipment (GW-HM)
- Request for Prior Authorization for Home Modification and/or Special Medical Equipment/Rehab Equipment (GW-EM1)
- Request for Prior Authorization for DME-children only
- Rental Property Agreement - Authorization for Home Modifications/Special Equipment (GW-RA)
- Severe Malocclusion Treatment Request Form
- Consent Form for Sterilization Procedures
- Consent Form for Sterilization Procedures - Spanish
- Hysterectomy Acknowledgement Form
- Hysterectomy Payment Form
- Home Stabilization Referral Form
- 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 Medicaid Disclosures
- Additional Federally Required Disclosures
- Exclusion Letter
- W-9 Form and Instructions
- Local Education Agency (LEA) Provider Form
- Home Care Transportation Certification
- Managed Care Organization (Only) Change Form
Applicants who wish to enroll as a RI Medicaid Trading Partner must complete the electronic application process. The application is accessed through the Healthcare Portal.
All existing Trading Partners are required to register in the Healthcare Portal.
- Prior Authorization Submission Process
- Prior Authorization Form
- Prior Authorization Form Instructions
- Prior Authorization Form - Chiropractor Providers Only
- MDS Home Care Agency Form
- Certificate of Medical Necessity
- Certificate of Medical Necessity for Community Health Worker (CHW) Units
- Certificate of Medical Necessity Instructions
- Certificate of Medical Necessity for Biomarker Testing
- Certificate of Medical Necessity for Disposable Gloves
- Certificate of Medical Necessity for Enteral Nutrition and Total Parenteral Nutrition
- Certificate of Medical Necessity for External Infusion Pump
- Certificate of Need for Hearing Aid
- Certificate of Medical Necessity for Hospital Beds
- Certificate of Medical Necessity for Enclosed Beds
- Certificate of Medical Necessity for Oxygen
- Certificate of Medical Necessity for Pressure Reducing Support Surfaces
- Certificate of Medical Necessity for Diabetic Shoes
- Director of Nurses Statement for Hearing Aids form
- Face-to-Face Encounter Documentation Form
- Home Modifications, Special Medical Equipment and Assistive Devices Services Form (GW-SF)
- Homeowner Property Agreement - Authorization for Home Modifications/Special Equipment (GW-HM)
- Request for Prior Authorization for Home Modification and/or Special Medical Equipment/Rehab Equipment (GW-EM1)
- Request for Prior Authorization for DME-children only
- Rental Property Agreement - Authorization for Home Modifications/Special Equipment (GW-RA)
- Severe Malocclusion Treatment Request Form
- Consent Form for Sterilization Procedures
- Consent Form for Sterilization Procedures - Spanish
- Hysterectomy Acknowledgement Form
- Hysterectomy Payment Form
- Home Stabilization Referral Form