Forms & Applications

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)
• Rite Share Enrollment Application - Add Members to Existing Group
• 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
• 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

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
• 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
• 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. 

• Electronic Funds Transfer
• Provider Change of Information Form
• Third Party Liability (TPL) Information Card

• 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 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 Prenatal Genetic Screening
• 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

• CMS-1500 Claim Form
  • CMS-1500 Claim Form Instructions
  • Billing NDC on the CMS 1500 form
• 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
• 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