The Rhode Island PM-1 form is the Medical Evaluation of Applicant for Level of Care, a document your healthcare provider completes so the state’s Office of Medical Review can decide whether you qualify for Medicaid Long-Term Services and Supports.1Executive Office of Health and Human Services. PM-1 Rhode Island Medical Evaluation Form It travels with the DHS-2 Application for Assistance as part of the Medicaid LTSS application package.2Executive Office of Health and Human Services. Medicaid LTSS Application The form itself is short, but the answers it captures decide whether the state will cover nursing facility care, home and community-based services, or neither.
Medicaid LTSS has two eligibility gates: a financial one and a clinical one. The PM-1 is how you clear the clinical gate.3Executive Office of Health and Human Services. Medicaid Long-Term Services and Supports
Who Is Allowed to Complete the PM-1
The form restricts sign-off to three types of licensed providers: a physician (MD or DO), a registered nurse practitioner (RNP), or a physician assistant (PA).1Executive Office of Health and Human Services. PM-1 Rhode Island Medical Evaluation Form A social worker, therapist, home health aide, or office staff member cannot complete the medical sections even if they know the patient’s situation in detail. The provider must print their name, sign, date the form, and note their credential type. If any of those four pieces is missing, the Office of Medical Review will reject the submission.
Choose a provider who actually knows the patient. Someone who treats the patient regularly can describe functional limitations in the specific terms the reviewer needs. A provider who has met the patient once will struggle to characterize how a diagnosis plays out across daily life. If the primary care provider is unavailable, a specialist familiar with the condition can complete the form instead.
What the Provider Must Document
The PM-1 is a functional assessment, not a general medical history. The provider needs to describe three things clearly: what the patient’s conditions are, what the patient can and cannot do in daily life, and how the patient is thinking and being treated right now.
Diagnoses in Plain Clinical Language
At the top of the form, the provider lists medical and behavioral diagnoses with severity. The form specifies “No Diagnosis Codes,” so ICD-10 numbers do not belong here.1Executive Office of Health and Human Services. PM-1 Rhode Island Medical Evaluation Form Write it out. “Moderate Alzheimer’s disease with frequent disorientation and nighttime wandering” tells the reviewer something. “Memory issues” does not.
The Nine Activities of Daily Living
The core of the form is a rating of the patient’s independence across nine ADLs. For each one, the provider should describe the actual limitation and note any assistive devices in use. Marking someone “dependent” for bathing without explanation gives the reviewer less to work with than noting that the patient cannot safely transfer into a shower without physical assistance because of lower-extremity weakness.
The nine ADLs assessed on the form are:1Executive Office of Health and Human Services. PM-1 Rhode Island Medical Evaluation Form
- Transfers between surfaces such as a bed, chair, wheelchair, or standing position, excluding bath or toilet transfers, with or without an assistive device.
- Ambulation between locations in the person’s living environment, with or without an assistive device.
- Bed mobility, including repositioning and turning side to side.
- Dressing: putting on, fastening, and removing all clothing items.
- Bathing: taking a bath, shower, or sponge bath thoroughly, and transferring in and out of a tub or shower.
- Toileting: transferring on and off the toilet, cleansing after elimination, managing pads, briefs, ostomy, or catheter equipment, and adjusting clothing.
- Eating with routine or adaptive utensils, including the ability to cut, chew, and swallow food.
- Personal hygiene: combing hair, brushing teeth, and washing and drying face, hands, and perineum.
- Medication management: identifying and taking medications correctly at the right time, by the right route, and at the right dose.
Cognitive Status and Current Treatments
A separate section captures cognitive function. The provider should document memory loss, impaired judgment, wandering, or difficulty with decision-making where any of those apply. Current treatments round out the picture: medications, therapies, scheduled procedures. The Office of Medical Review uses this information to judge whether community-based services can safely meet the patient’s needs or whether institutional care is required.
Signature Block
At the bottom, the provider prints their name, signs, dates, and marks their credential (MD, DO, RNP, or PA). A form missing any of these elements comes back, and the whole application waits.
Where to Download the Form
The PM-1 is posted on the Rhode Island Executive Office of Health and Human Services website under Forms & Applications.4Executive Office of Health and Human Services. Forms and Applications It is also linked from the Medicaid LTSS Application page alongside the DHS-2 and the CP-12 Home and Community Based Waiver notification form.2Executive Office of Health and Human Services. Medicaid LTSS Application Print the PDF and bring it to the appointment with your provider.
Where to Submit the Completed Form
Once the provider has signed the PM-1, submit it to the Rhode Island Department of Human Services along with your DHS-2 application. DHS has walk-in offices and secure drop boxes around the state:5Rhode Island Department of Human Services. DHS Offices
- Providence: 125 Holden Street, Providence, RI 02908. Walk-in, document scanning center, indoor drop box.
- Pawtucket: 249 Roosevelt Avenue, Pawtucket, RI 02860. Walk-in, document scanning center, indoor drop box available 8:00 a.m. to 4:30 p.m.
- Woonsocket: 219 Pond Street, Woonsocket, RI 02895. Walk-in, indoor and outdoor drop boxes.
- Wakefield (South County): 4808 Tower Hill Road, Suite G1, Wakefield, RI 02879. Walk-in, outdoor drop box.
- Middletown (Newport County): 31 John Clarke Road, Middletown, RI 02842. Walk-in, outdoor drop box.
Two additional offices operate by appointment only but have drop boxes if you only need to leave paperwork: the Shepard Building at 80 Washington Street in Providence and the Hazard Building at 41 West Road in Cranston.5Rhode Island Department of Human Services. DHS Offices For help working through the LTSS application, the state directs applicants to The POINT at (401) 462-4444.2Executive Office of Health and Human Services. Medicaid LTSS Application
What Happens After You Submit
Once DHS has the completed PM-1 and the rest of the application package, the form moves to the Office of Medical Review for a level-of-care determination.1Executive Office of Health and Human Services. PM-1 Rhode Island Medical Evaluation Form The OMR decides whether the applicant meets the clinical threshold for nursing facility-level care. Meeting that threshold does not force a move into a nursing home. Rhode Island offers home and community-based alternatives for people who qualify clinically but want to receive services where they live, and the CP-12 form in the application package documents the applicant’s choice between facility and community-based options.2Executive Office of Health and Human Services. Medicaid LTSS Application
If the OMR finds the PM-1 incomplete or the clinical information too vague to act on, the review stalls while DHS goes back to the provider for more detail. This is the most common avoidable delay, and it is why the ADL descriptions and the diagnosis narrative are worth the time to get right the first time.
If the Office of Medical Review Denies the Level of Care
A denial is not the end of the road. Federal regulations require every state Medicaid program to offer a fair hearing to anyone whose claim is denied or not acted on promptly.6eCFR. 42 CFR 431.220 – When a Hearing Is Required In Rhode Island, those hearings run through the Executive Hearing Office.
If you are enrolled in a Medicaid managed care plan, state regulations generally require you to go through the plan’s internal grievance and appeal process before requesting a fair hearing.7Cornell Law Institute. 210 RICR 10-05-2.4 Federal rules then give you 120 calendar days after exhausting the plan’s appeals to request a fair hearing. In urgent cases where waiting could jeopardize your health, you can request an expedited appeal; for dual Medicare-Medicaid beneficiaries, an expedited appeal must be resolved within three business days.
Before the hearing, ask for your complete case file, including the medical records and review criteria the state used. If your provider can supply additional or updated evidence that was not part of the original PM-1, bring it. A supplemental letter from the provider explaining why the ADL limitations documented on the form require a nursing facility level of care can carry real weight at the hearing.