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Provider Forms

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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