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| Assigned Number | Title | Other Location |
|---|---|---|
| F-01352B | IRIS Participant-Hired Worker Background Check Appeal Process - Ineligible Letter | None |
| F-01442C | IRIS Program Disenrollment Letter – No Contact | None |
| F-01942A | LTC FS - Diagnosis Verification Letter | None |
| F-02400A | Client Transfer: Assisted Living Facility Capability | None |
| F-01454C | IRIS Program Withdrawal Letter – No Contact | None |
| F-01628 | OARS Enrollment Letter | None |
| F-01556C | IRIS Program Cost Share Repayment Plan Letter | None |
| F-01894 | Vendor Overpayment Findings Letter | None |
| F-01442K | IRIS Program Disenrollment Letter - Policy Noncompliance | None |
| F-01442E | IRIS Program Disenrollment Letter – Ineligible Setting | None |
| F-01942B | LTC FS - Request Letter | None |
| F-01556E | IRIS Medicaid Cost Share Letter - Fiscal Employer Agent Transfer | None |
| F-02400B | Client Transfer: Labels | None |
| F-01454D | IRIS Program Withdrawal Letter – Non Eligible Setting | None |
| F-01556D | IRIS Program Letter – Disenrollment | None |
| F-01556BB | IRIS Program Previous Delinquent Medicaid Cost Share Payment Letter | None |
| F01454G | IRIS Program Withdrawal Letter - Cancelled | None |
| F-22538 | Consent to Photograph or Record and Use of Photographs/Recordings | None |
| F-01205K | IRIS Participant Education: Annual Health Care Information | None |
| F-01684 | Community Mental Health Allocation (CMHA) Report | None |
| F-02383 | HCBS Heightened Scrutiny Reviewer Assessment and Evidentiary Summary | None |
| F-01205D | IRIS Participant Education: Program Integrity - Fraud Prevention | None |
| F-00251 | Mental Health Block Grant Community Aids Allocation Report | None |
| F-01205E | IRIS Participant Education: Program Integrity - Budget Monitoring | None |
| F-01205F | IRIS Participant Education: Complaints and Grievances | None |
| F-01205 | IRIS Participant Education: Self-Direction Responsibilities | None |
| F-01205A | IRIS Participant Education: Health and Safety - Incident Reporting | None |
| F-44024A | WIC Request for Medical Food: Pregnant, Breastfeeding, and Nonbreastfeeding Postpartum Women | None |
| F-01205I | IRIS Participant Education: Program Integrity - Conflict of Interest | None |
| F-00913 | Annual Survey of Nursing Homes | None |
| F-02140 | Urgent Services Agreement | None |
| F-02382 | HCBS Heightened Scrutiny Residential Provider Evidentiary Worksheet | None |
| F-00221 | Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions | None |
| F-00534 | Pace and Partnership Member Requested Disenrollment or Transfer and Instructions | None |
| F-00076 | Variance Request – WaitList | None |
| F-21059 | Variance Request for Institution Respite | None |
| F-00533 | PACE / Partnership Programs - Enrollment | None |
| F-21063 | Exception to Care Management / Support and Service Coordination Contact Requirements | None |
| F-02047 | IRIS Financial Reporting Template | None |
| F-00607 | Complaint Intake Survey | None |
| F-01947 | IRIS Participant Education Manual: Acknowledgement | None |
| F-02403 | Family Care, Partnership, PACE, and IRIS Program Requested Disenrollment | None |
| F-00615 | Change Project Report and Instructions | None |
| F-02435 | Support and Service Coordinator Waiver Basics Training Requirement Attestation | None |
| F-01567 | Long-Term Care Insurance Policy – Assignment of Benefits | None |
| F-02371 | Prior Authorization Drug Attachment for Migraine Agents, Calcitonin Gene-Related Peptide (CGRP) Antagonists | None |
| F-14014 | Authorization to Disclose Information to Disability Determination Bureau (DDB) | None |
| F-62504 | Behavioral Health Certification Section: Initial Certification Application | None |
| F-02432 | IRIS Program HIPAA Breach and Unauthorized Disclosure Reporting | None |
| F-20920 | Formula to Determine Amount of Income Available to Pay for Room & Board in Substitute Care | None |
Pages
Last Revised: May 22, 2018
