Eohhs ri reference-centerforms-applicationsMedicaid LTSS ApplicationExecutive Office - Rhode Island 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Provider ID at the top of the form. This is essential for identifying your records.
3. Fill in your Provider Name and current Address On File. Ensure that all details are accurate to avoid processing delays.
4. If you are changing your address, check the 'Address Change' box and provide the new address details, including street, city, state, and zip code. Remember to upload a verification document like a utility bill.
5. For a name change, check the corresponding box and enter your new name. Attach a copy of your new Social Security Card as verification.
6. If updating your phone number or email address, fill in the new information and ensure you provide supporting documents as required.
7. List any changes in household members by providing their names, sex, date of birth, SSN, and date moved in. This information is crucial for compliance checks.
8. Finally, review all entered information for accuracy before signing and dating the form at the bottom.

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