Rhode Island DHS

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Provider Forms

 

Provider Enrollment Application & Related Forms

 Provider Enrollment Application   Provider Agreement
 W-9 Form     W-9 Form Instructions  Addendum I

The above link for enrollment includes the Provider Enrollment Application, Group Member Enrollment Form, Provider Agreement Form, Addendum I, Enrollment Instructions, Medical Specialty list. A W-9 form is also necessary with your application. All documents require signatures for processing program enrollment.

 Authorization for Direct Deposit   RIte Share Enrollment Application
 Out of State Questionnaire  Local Education Agency (LEA) Provider
 Linkage Form
 Hospital Room and Board Revenue Codes  Provider Change of Information Form

 

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 Procedures
 Certificate of Need for Hearing Aid  Hysterectomy Consent Form
   
Request for Prior Authorization for Rehab/Adaptive Equipment  

 

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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