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ADRC Forms

Enrollment Forms:

• Family Care Enrollment Form (F-00046)
• IRIS Referral/Authorization Form (F-00075)
• PACE/Partnership Enrollment Form (F-00533)

Disenrollment Forms:

• Family Care/IRIS Member Requested Disenrollment - Instructions (F-00221I)
• Family Care/IRIS Member Requested Disenrollment Form (F-00221)
• PACE/Partnership Member Requested Disenrollment Form - Instructions (F-00534I)
• PACE/Partnership Member Requested Disenrollment Form (F-00534)
• Family Care/Partnership/PACE/IRIS - Change Routing Instructions (F-00221AI)
• Family Care/Partnership/PACE/IRIS - Change Routing Form (F-00221A)
• Family Care/Partnership/PACE/IRIS - Refusal to Accept Services and Program Requested Disenrollment Form (F-00221B)

Request for Waiver Forms:

• Request for Waiver of Education and Experience Requirements
• Request for Waiver of Requirements Related to Co-location
• Request for Waiver of Requirements Related to Separation
• Request for Waiver of the .5 Full-Time Equivalent Requirement for ADRC Staff

DHS Forms Library

Last Revised: September 17, 2012