Participant Education
- Self-Direction Responsibilities, F-01205 (Word)
- Health and Safety-Incident Reporting, F-01205A (Word)
- Program Integrity - Fraud Prevention, F-01205D (Word)
- Program Integrity - Budget Monitoring, F-01205E (Word)
- Complaints and Grievances, F-01205F (Word)
- Notices of Action and Appeals, F-01205G (Word)
- Program Integrity - Conflict of Interest, F-01205I (Word)
- Annual Health Care Information, F-01205K (Word)
- Restrictive Measures, F-01205M (Word)
- Background Check Process, F-01205P (Word)
- Self-Directed Personal Care, F-01205J (Word)
- Budget Amendments, F-01205B (Word)
- One-Time Expense Requests, F-01205C (Word)
Participant-Specific Forms
- Orientation and Enrollment Checklist, F-01309 (Word)
- Medical and Remedial Expense Checklist, F-00295 (Word)
- Accessibility Assessment, F-01213 (Word)
- Conflict of Interest Disclosure - Participant, F-01310A (Word)
- Risk Agreement - IRIS Program, F-01558 (Word)
- Participant-Hired Worker 40-Hour Health and Safety Assurance Exception Request, F-01689 (Word)
- Fiscal Employer Agent Selection, F-01293 (Word)
- Cost Share Repayment Agreement, F-01200 (Word)
- Participant Fiscal Employer Agent Change Request, F-01293A (Word)
- FEA Transfer Checklist, F-01293D (Word)
IRIS Self-Directed Personal Care (SDPC)
Rights and Responsibilities
Budget Amendments and One-Time Expenses
- Budget Amendment Request, F-01210 (Word)
- Budget Amendment Provider Quote Comparison, F-01210A (Word)
- Budget Amendment Annual Verification (BAAV) Request, F-01210B (Word)
- One-Time Expense Request, F-01206 (Word)
- One-Time Expense Vendor Bid Comparison, F-01206A (Word)
- One-Time Expense Request - Ramp, F-01206B (Word)
Background Check and Disclosure
Participant-Hired Worker Specific
- Participant-Hired Worker Employee Set-Up, F-01201 (Word)
- IRIS Participant-Hired Worker Relationship Identification, F-01201A (Word)
- Supportive Home Care/Self-Directed Personal Care/Respite Care Training Verification, F-01201B (Word)
- Employer/Employee Agreement, F-01201C (Word)
- Medicaid Provider Agreement, F-00180B (Word)
- Application for Employer Identification Number, FSS-4 (PDF)
- Employer/Payer Appointment of Agent, F2678 (PDF)
- Form W-4 (PDF)
- Employment Eligibility Verification, I-9 (PDF)
Vendor Specific
ICA and FEA Specific
- IRIS Certification Acknowledgement, F-01209 (Word)
- IRIS Critical Incident Reconciliation, F-01240 (Word)
- IRIS Involuntary Disenrollment Request, F-01319 (Word)
- IRIS Denial of Enrollment Request, F-01319B (Word)
- IRIS Self-Directed Personal Care (SDPC) Involuntary Disenrollment Request, F-01319D (Word)
- IRIS Program Conflict of Interest Disclosure - Provider, F-01310 (Word)
- Employment Checklist, F-01314 (Word)
- WISITS User Setup Request Form, F-01578 (Word)
- Sharepoint User Setup Request Form, F-01578A (Word)
- Family Care/IRIS Participant-Requested Disenrollment or Transfer and Instructions, F-00221 (Word)
- Family Care/Partnership/PACE/IRIS Change Routing and Instructions, F-00221A (Word)
- Family Care/Partnership/PACE/IRIS Program Requested Disenrollment, F-00221B (Word)
Guardian Specific
Last Revised: August 8, 2018
