Rhode Island DHS

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Provider Enrollment Information and Forms

Please read information provided under applicable section. Instructions are provided for each area. The provider enrolment team is also available to answer questions. Please call Barbara Lynch at (401) 784-3840, or Dianne Folco at (401) 784-3830. Provider forms must contain complete information. All incomplete applications will be returned with a letter listing deficient and/or additional items necessary to continue processing.

Please click the link(s) below for additional information and forms.
 

Individual Providers Local Education Agency (LEA) Provider Linkage Form
New Groups New Provider Joining an Established Group
RIte Share Co-Pay Only Provider Enrollment Form  


MISC. FORMS

Authorization for Direct Deposit
Provider Change of Information Form

You can benefit from Interactive Web Services by completing a Trading Partner Agreement form

Click here for information on free electronic billing using EDS’ proprietary software PES (Provider Electronic Solutions)

 

Related Business Process Forms

 Single Claim Adjustment Form  Trading Partner Agreement
 Multiple Claim Adjustment Form  Trading Partner Agreement Add/Change Form
 Refund Log  Point of Service Application
   
 Prior Authorization Form  Third Party Liability (TPL) Form
 MDS MOD Home Care Agency Form  
 Certificate of Medical Necessity  Consent Form for Sterilization
 Certificate of Need for Hearing Aid  Hysterectomy Consent Form
 Director of Nurses  
   
Request for Prior Authorization for Rehab/Adaptive Equipment Request for Prior Authorization for Durable Medical Equipment(DME) - Children Only
  Request for Disposable Gloves

 

Claim Forms and Instructions

 CMS-1500 Claim Form Instructions  CMS-1500 Claim Form
 UB-04 Claim Form Instructions  UB-04 Claim Form
 Dental Claim Form Instructions  Dental Claim Form
 Pharmacy Claim Form Instructions  Pharmacy Claim Form
 Waiver Claim Form Instructions  Waiver Claim Form
 NDC Attachment Form Instructions  NDC Attachment Form

 

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