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Fillable Online dhs ri ri rite care application form Fax 2026

The document is a claim form for the Unique Services Reimbursement Program offered by Presbyterian Health Plan, intended for employees and their eligible dependents to request reimbursement for specific medical expenses. It includes instructions on how to complete the form, required documentation, and types of reimbursable expenses such as gym memberships, LASIK surgery, and dental treatments. The form must be mailed to the specified address, and assistance is available through customer service.

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Click ‘Get Form’ to open it in the editor.
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.
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.
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.
Finally, review all entries for accuracy before submitting your completed form via mail as faxes are not accepted.

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What is the monthly income limit for Medicaid in Rhode Island?

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

How do I apply for RI works?

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).

How to apply for free health insurance in Rhode Island?

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.