Skip to guide content
Exchange Agreements

HealthSource RI

You hereby authorize Stride Health, Inc. to act as your Broker of Record in connection with this Application, and you acknowledge and agree that Stride Health, Inc. may use your personally identifiable information in order to complete the eligibility and enrollment process on HealthSource RI. By submitting your application, you agree to the HealthSource RI User Acceptance Agreement. You also acknowledge and agree to the following:

##Application Agreement I have agreed to submit this Application electronically. By signing this application electronically, I certify and attest under penalty of perjury that my answers are correct, including information about citizenship and alien status, and complete to the best of my knowledge.

  • I understand the questions and statements on this application.

  • I understand the penalties for providing false information, including penalties for violation of the Rhode Island False Claims Act, RIGL 9-1-1 et. al.

  • I understand that the agency may contact other persons or organizations for a variety of reasons concerning my application, including but not limited to verification of Medicaid Affordable Care Coverage Group Eligibility Factors, EOHHS Rules and Regulations, Section 1308.

  • I know that under the state of Rhode Island General Laws, Section 40-6-15, a maximum fine of $1,000, or imprisonment of up to five (5) years, or both, may be imposed for a person who obtains or attempts to obtain, or aids or abets any person to obtain, public assistance to which he or she is not entitled or who willfully fails to report income, resources, or personal circumstances or increases therein which exceed the amount previously reported.

  • I understand that an electronic signature has the same legal effect as a written signature and can be enforced in the same way and that my Electronic Signature and this Electronic Signature Agreement are pursuant to RIGL 42-127.1, Uniform Electronic Transactions Act, and in accordance with RIGL 2-35, Administrative Procedures Act.

  • Under penalty of perjury, I attest to the identity of the minor children identified herein and that all of the information contained in this application is true. I understand that I am breaking the law if I give wrong information and can be punished under federal law, state law or both.

By checking this box and typing my name below, I am electronically signing my application.

##Authorization for HSRI to Request Income Data Before you continue, we require you to acknowledge the following. I have read and agree to the Consent to Share Data for Eligibility Decisions. I have read and agree to my Consent for Use of Income Data.

Check the box below only if all of these apply to you:

  • You used advance payments of premium tax credits (APTC) in 2016 to help lower your costs for Marketplace coverage.

  • The tax filer(s) for your household filed a federal income tax return for 2016.

  • The tax return compared the amount of APTC used in 2016 to the rest of the tax return information.