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Provider Forms 

You'll find all forms we currently use in the following list. Check back frequently for the current and most up-to-date forms.


Prior Authorization Forms

Gaucher's Disease Enzyme Therapy Prior Authorization Form (PDF 231.04 KB)
Botulinum Toxins Prior Authorization Form (PDF 508.18 KB)
HP Acthar Gel Prior Authorization Form (PDF 225.57 KB)
Immune Globulin Prior Authorization Form (PDF 232.69 KB)
Makena Prior Authorization (PDF 228.57 KB)


Provider Manual

Rhode Island Provider Manual (PDF 3.15 MB)


Other Forms

Group Disclosure of Ownership and Control of Interest Form click here (PDF 519.75 KB) for PDF version.

Individual Disclosure of Ownership and Control of Interest Form click here (PDF 427.75 KB) for PDF version.

Provider Disclosure of Ownership and Control Interest Statement - FAQ (PDF 256.6 KB)

Asthma Care Guidelines Flow Sheet (Ages 0-4) (PDF 958.58 KB)

Asthma Care Guidelines Flow Sheet (Ages 5-11) (PDF 1.19 MB)

Asthma Care Guidelines Flow Sheet (Ages 12 - 50) (PDF 1,013.93 KB)

Diabetes Care Guidelines Flow Sheet (PDF 604.18 KB)

Diabetic Eye Health Examination Report (PDF 26.96 KB)

Early Periodic Screening Diagnosis & Treatment (PDF 106.24 KB)

HEDIS Coding and Billing Quick Reference Guide (PDF 672.04 KB)

Interpreter Request Form (PDF 122.36 KB)

Medicaid Pediatric Oral Health Schedule (PDF 107.58 KB)

Member Consent Form for Provider Representation (PDF 19.21 KB)

Member Education Form (PDF 32.35 KB)

Obstetrical Health Risk Assessment Form (Medicaid) (PDF 40.68 KB)

Primary Care Physician (PCP) Form (PDF 40.42 KB)

Pregnancy Notification Form (PDF 40.66 KB)

Sleep Study FAQ (PDF 144.85 KB)

Sterilization Request Form (PDF 73.05 KB)

Third Party Liability Coordination of Benefits Form (Medicaid) (PDF 205.41 KB)

Prior Authorization Request Form - RX (PDF 52.76 KB)

Prior Authorization Fax Form Request (PDF 95.52 KB)

Specialty Medication Prior Authorization Cover Sheet (PDF 20.13 KB)

CPT (Current Procedural Terminology) Codes Radiology Crosswalk Table (PDF 470.12 KB)


Medical Injectables

View the clinical criteria/guidelines used to conduct medical necessity reviews.