Rhode Island Executive Office of Health and Human Services Forms

This Form is used for referring individuals in Rhode Island who require preventive or medically complex services.

This document is used for obtaining medical statements from providers in Rhode Island.

This form is used for obtaining authorization for home modifications or special equipment for rental properties in Rhode Island.

This Form is used for requesting treatment for severe malocclusion in Rhode Island.

This Form is used for enrolling as an individual provider in the Rite Share program in Rhode Island.

This form is used for submitting a waiver/rehabilitation claim in the state of Rhode Island. It provides instructions on how to complete the form and submit it for consideration.

This document is used for reporting changes to the Long-Term Services and Supports (LTSS) program in Rhode Island.

This document is an Exhibit C Estate Recovery Funeral Home Attestation specific to Rhode Island. It is used for the purpose of verifying funeral home expenses in relation to estate recovery.

This Form is used for requesting home care services in Rhode Island.

This document is a notarized statement in Rhode Island that is related to the amount of personal needs money available upon a resident's death. It is used to provide information about the funds available for personal expenses after the death of a Rhode Island resident.

This document is for participants in the Rhode Island Pediatric Primary Care Relief Program. It outlines the financial agreement and requires attestation from the participants.

This document is for the Medicaid Pediatric Primary Care Rate Supplement Program in Rhode Island. It outlines the financial agreement and attestation requirements for healthcare providers participating in the program.

This document is a survey for Rhode Island Medicaid members who speak Hmong.

This document is a questionnaire used to gather information about assisted living residences in Rhode Island.

This type of document is a referral form for assisted living enhanced care in Rhode Island.

This type of document is used for conducting an enhanced care assessment in Rhode Island.

This Form is used for notifying the state of Rhode Island about a discharge.

This document is a survey specifically designed for Medicaid members in Rhode Island. It aims to gather feedback and opinions from Medicaid recipients in the state.

This Form is used for requesting a replacement or return of a FVV device in Rhode Island.

This document is used for tracking the transition process of students with disabilities in Rhode Island.

This form is used to submit a request for a FVV (Futuristic Vehicle Vehicle) in Rhode Island.

This document is used to certify the medical necessity of using disposable gloves in Rhode Island.

This document is used to certify the medical necessity for enteral and parenteral nutrition in Rhode Island.

This Form is used for obtaining a Certificate of Medical Necessity for Pressure Reducing Support Surfaces in Rhode Island. It is required to be filled out by a healthcare provider to justify the need for this type of equipment for a patient's medical condition.

This form is used for reassigning a tax ID for Mapir in Rhode Island.

This document is used to certify the medical necessity for diabetic shoes in the state of Rhode Island.

This document is used to certify the medical necessity of an external infusion pump in Rhode Island.

This form is used for health insurance claim submission in Rhode Island. It provides instructions on how to fill out the CMS-1500 form accurately.

This document is used for certifying the medical necessity of hospital beds in Rhode Island. It is required to ensure that patients who need a hospital bed at home receive proper medical care.

This document is used for documenting the face-to-face encounter required for Medicaid in Rhode Island. It ensures that the recipient has been examined by a healthcare provider before receiving certain services.

This Form is used for requesting home modifications or special medical equipment in Rhode Island. It helps individuals with disabilities or medical conditions make their homes more accessible.

This Form is used for referring requests for home stabilization services in Rhode Island.

This Form is used for residents of Rhode Island to request prior authorization for home modifications, special medical equipment, and minor environmental modifications.

This document provides detailed information about the NDC (National Drug Code) Detail Attachment for the Rhode Island Medicaid Program in Rhode Island. It outlines the specifics of drug codes and their attachment to the program.

This form is used for obtaining prior authorization for Medicaid services in Rhode Island. It helps ensure that necessary medical treatments are approved and covered by Medicaid.

This document provides instructions for completing the Rhode Island Medicaid Prior Authorization Form. It is used to request approval for specific medical services or treatments before they can be covered by Medicaid in Rhode Island.

This document is used to request prior authorization for durable medical equipment (DME) specifically for children in Rhode Island. It helps ensure that children have access to necessary medical equipment.

This document is used to certify the medical necessity of hearing aids in Rhode Island.