Fillable Enrollment / Re- Enrollment form - RI Department of Human Services - dhs ri

DEPARTMENT OF HUMAN SERVICES INDIVIDUAL PROVIDER ENROLLMENT FORM Provider Number only) Link ID (Shaded Area for HP Enterprise Services use STATE OF RHODE ISLAND 1. 2. 3. 4. Provider Name Business Name (if applicable) Business Type Sole Other (Attach supporting documentation) Name Type Census Tract Cnty Code Town Code Location Owner/Administrator,
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