Skip to main content

Jump to: Administrative Forms & Notices | Prior Authorization Forms | CMS Provider Directory Requirements

Refer a Patient

Together we can create a better experience and better outcomes for your patients with complex needs.

Administrative Forms and Notices

Appointment of Representative (Form CMS-1696)*

2024 PA Select Drug Exception List – Rhode Island

2024 Prior Authorization Requirements – Rhode Island

Coverage Requests and Determination – Rhode Island

Learn how we make coverage decisions and how to make requests for coverage.

2024 Durable Medical Equipment – Rhode Island

2024 Ambulatory – Outpatient Surgery Exception List – Rhode Island

Notice of Privacy Practices – Rhode Island

Commonwealth Care Alliance, Inc., is required by law (i) to protect the privacy of your Medical Information

The Patient Health Questionnaire 2 Overview (PHQ 2)

The Patient Health Questionnaire (PHQ 9)

Mental Status Exam

CAGE Questionnaire

Prior Authorization Forms

FAQs: Prior Authorization Requests – Rhode Island

Esketamine Prior Authorization Request

PA Form – Repetitive Transcranial Magnetic Stimulation Request (RI)

PA Form – Out of Network Psychological & Neuropsychological Assessment (RI)

PA Form – Cardiac Imaging


PA Form – PET – PET CT

Standard Prior Authorization Request Form

Out of Network ECT Authorization Request

CMS Provider Directory Requirements

Guidance to Verify Adequate Networks & Current Provider Directories

Provider Directory Requirements

Other Important Forms

Chronic Condition Provider Attestation Form

Need more information?
We’re here to help.