Form PR0060 Claim Adjustment Request Form - Medicaid Program - Rhode Island
Request for Re-review of Medicare Claims Related to the Settlement Agreement in Ryan V. Price
Medicaid Health Plan Change Request Form - Rhode Island
Form HCFA-605 Request for Approval as a Hospital Provider of Extended Care Services (Swing-Bed) in the Medicare and Medicaid Programs
Form ICN006973 Medicare Claim Review Programs
VA Form 10-0491J Request for Deferment for Advanced Education - Health Professional Scholarship Program (Hpsp) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (Viompsp)
Form R0062 Refund Request - Medicaid Program - Rhode Island
DD Form 2642 CHAMPUS Claim Patient's Request for Medical Payment
Form CMS-417 Hospice Request for Certification in the Medicare Program
VA Form 10-0527-CHOICE Request and Authorization to Release Protected Health Information to the Choice Program
VA Form 10-7959f-2 Foreign Medical Program (FMP) Claim Cover Sheet
VA Form 10-0491G Application for Health Professional Scholarship Program (Hpsp), Visual Impairment and Orientation and Mobility Professionals Scholarship Program (Viompsp), &veterans Healing Veterans Medical Access and Education Scholarship Program (Vhvmaesp)
DD Form 2569 Third Party Collection Program/Medical Services Account/Other Health Insurance
IRS Form 1065-X Amended Return or Administrative Adjustment Request (AAR)
IRS Form 8082 Notice of Inconsistent Treatment or Administrative Adjustment Request (AAR)
FCC Form 500 Universal Service for Schools and Libraries Funding Commitment Adjustment Request Form
Form CMS-179 Transmittal and Notice of Approval of State Plan Material for: Centers for Medicare & Medicaid Services
Form CMS-R-0235A Data Use Agreement (Dua) Signature Addendum for Data Acquired From the Centers for Medicare & Medicaid Services (Cms)
IRS Form 8453-PE E-File Declaration for Form 1065, 2023
Formulario PS6D Autorizacion Para Revelar Informacion Confidencial Programas De Tratamiento Para La Salud Mental (Spanish)
Form EE-4 Employment History Affidavit for a Claim Under the Energy Employees Occupational Illness Compensation Program Act
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