Member Forms

Need to update your information or make changes to your CurrentCare enrollment status? Simply download and complete the appropriate form below and return the completed document to:

Rhode Island Quality Institute
50 Holden St., Suite 300
Providence, RI  02908

Request to Amend Demographics [PDF, 149KB]

Use this form to update your name, address, phone number or other personal information. For your protection, we require your signature be witnessed and verified by an Authorized Representative, including a member of your health care provider’s office, a notary public or an authorized RIQI employee.

 

Request to Amend Consent [PDF, 154KB]

Use this form to change your CurrentCare Consent Option. Option 1: Authorizes access to your medical records by all of your doctors, including emergency situations. Option 2: Authorizes access only in emergency situations. Option 3:  Allows you to authorize access by only the healthcare providers you designate.  For your protection, we require your signature be witnessed and verified by an Authorized Representative, including a member of your health care provider’s office, a notary public or an authorized RIQI employee.

 

Cancellation of Authorization [PDF, 148KB]

Use this form if you wish to revoke your CurrentCare enrollment/authorization. For your protection, we require your signature be witnessed and verified by an Authorized Representative, including a member of your health care provider’s office, a notary public or an authorized RIQI employee.

Alternative Methods for Terminating Your Participation in CurrentCare [PDF, 294KB]

 

Access Request Form [PDF, 148KB]

Use this form to request a copy of your health information record in Currentcare. For your protection, we require your signature be witnessed and verified by an Authorized Representative, including a member of your health care provider’s office, a notary public or an authorized RIQI employee.

Alternative Methods for Obtaining a Copy of Your CurrentCare Record [PDF, 269KB]

 

Provider Cancellation Form [PDF, 149KB]

Use this form to cancel your authorization for provider organization(s) to access your health information in Currentcare. For your protection, we require your signature be witnessed and verified by an Authorized Representative, including a member of your health care provider’s office, a notary public or an authorized RIQI employee.

 

Amend Record Request [PDF, 148KB]

Use this form to request an amendment of your health information record in Currentcare. For your protection, we require your signature be witnessed and verified by an Authorized Representative, including a member of your health care provider’s office, a notary public or an authorized RIQI employee.

 

Disclosure Report [PDF, 149KB]

Use this form to request a copy of your disclosures of health information in Currentcare. For your protection, we require your signature be witnessed and verified by an Authorized Representative, including a member of your health care provider’s office, a notary public or an authorized RIQI employee.

 

Complaint Form [PDF, 14KB]

Use this form to submit a complaint about Currentcare.