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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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