Rhode Island Executive Office of Health and Human Services Forms

This form is used for requesting prior authorization in Rhode Island for home modifications and/or special medical equipment/rehab equipment.

This document provides answers to frequently asked questions regarding the disclosure of Medicaid benefits in the state of Rhode Island. Find information on eligibility requirements, coverage options, and more.

This Form is used for creating a linkage between the local education agency (LEA) and a provider in Rhode Island. It facilitates collaboration between educational institutions and service providers for the benefit of students.

This document is used for authorizing electronic financial transactions in Rhode Island. It allows individuals to set up automatic payments or transfers through their bank accounts.

This Form is used for providing information about a Template Information Card in Rhode Island.

This type of document is used for adding new members to an existing group insurance enrollment in Rhode Island.

This document certifies that a home care agency provider in Rhode Island complies with the requirement of providing transportation services to individuals receiving Medicaid long term services and supports.

This Form is used for enrolling new groups in Rhode Island for Rite Share Co-insurance and Deductible Only plans.

This form is used for the Director of Nurses to make a statement regarding the need for hearing aids in Rhode Island.

This form is used for submitting a waiver or rehabilitation claim in the state of Rhode Island. It allows individuals to request exemptions or assistance for certain programs or services.

This form is used for applying for preferred provider status (PPS) in Rhode Island for the treatment of Hepatitis C.

This Form is used for requesting an early refill of a prescription that was lost or stolen in Rhode Island.

This form is used for submitting a claim recoupment request in Rhode Island.

This document is for individuals who are interested in becoming a member of the Rhode Island Consumer Advisory Board. Apply now to have your voice heard and contribute to consumer protection in Rhode Island.

This form is used for authorizing the release or obtaining of confidential information in the state of Rhode Island.

This document is used for referring individuals to Rhode Island's Nursing Home Transition Program, which helps individuals transition from nursing homes back to their homes or community-based settings.

This form is used for Level I identification for minors and individuals with developmental disabilities in Rhode Island.

This document is a sample Medicaid Managed Care Core Contract Attestation Statement for MCO Reporting Submission in Rhode Island.

This Form is used for making Medicare premium payments in Rhode Island.

This form is used for applying for state-funded assistance in Rhode Island to help pay for health care coverage.

This document is used for requesting value-added services (VAS) in Rhode Island.

This form is used for requesting a change in the licensed bed capacity of a nursing facility in Rhode Island.

This document is used for applying for a tier designation in the Assisted Living Certification Application in Rhode Island.

This form is used for requesting prior authorization and determining the fee for service for drugs treating Hepatitis C in Rhode Island.

This form is used for making changes to your Long-Term Services and Supports (LTSS) plan in Rhode Island.

This form is used for requesting a refund from the Medicaid Program in Rhode Island.

This document is an assessment tool used by Rhode Island for Certified Community Behavioral Health Clinic (CCBHC) applicants.

This document is used for financial agreement and attestations for the Medicaid Pediatric Healthcare Recovery Program in Rhode Island. It outlines the terms and conditions for receiving financial assistance for pediatric healthcare services.

This type of document is used in Rhode Island to certify the medical necessity of biomarker testing. It helps healthcare providers determine the appropriate course of treatment for patients based on their specific medical needs.

This document is for adding members to a new or existing group provider application in Rhode Island.