Fillable Online dhs ri ri rite care application form Fax 2026

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by filling out the Employee Information section. Enter your first name, middle initial, last name, and member ID number. Ensure that you provide a physical address (no P.O. Boxes) along with your city, state, county, ZIP code, and contact numbers.
  3. Next, move to the Unique Services Reimbursement Program Request section. List the names of all eligible dependents who received services. For each dependent, specify their relation to you and include the date of service, type of service provided, and the amount incurred.
  4. Attach any required documentation such as original itemized receipts and ensure they are taped securely if small. Remember to sign and date the form before submission.
  5. Finally, review all entries for accuracy before submitting your completed form via mail as faxes are not accepted.

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Income Asset Limits for Eligibility 2025 Rhode Island Medicaid Long-Term Care Eligibility for Seniors Type of MedicaidSingleMarried (both spouses applying) Regular Medicaid / Elders and Adults with Disabilities (EAD) $1,304 / month $1,763 / month3 more rows Jun 5, 2025
HealthSource RI is the states marketplace for buying and comparing health insurance plans. Individuals apply for health coverage through HSRI and depending upon their income, they may be eligible for Medicaid or eligible to purchase an insurance plan (possibly with financial assistance).
Apply on-line at: healthyrhoderi.gov. You can upload necessary documents. A DHS worker will determine eligibility for RI Works (and for SNAP if you are also applying for that benefit) and eligibility for RIte Care will also be determined.

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