IRIS Forms

Participant Specific

Participant Education: Self-Direction Responsibilities (F-01205) (Word)
Hmong (F-01205H) (Word)
Russian (F-01205R) (Word)
Spanish (F-01205S) (Word)

Participant Education: Health and Safety-Incident Reporting (F-01205A) (Word)
Hmong (F-01205AH) (Word)
Russian (F-01205AR) (Word)
Spanish (F-01205AS) (Word)

Participant Education: Budget Amendments (F-01205B) (Word)
Hmong (F-01205BH) (Word)
Russian (F-01205BR) (Word)
Spanish (F-01205BS) (Word)

Participant Education: One-Time Expense Requests (F-01205C) (Word)
Hmong (F-01205CH) (Word)
Russian (F-01205CR) (Word)
Spanish (F-01205CS) (Word)

Participant Education: Program Integrity - Fraud Prevention (F-01205D) (Word)
Hmong (F-01205DH) (Word)
Russian (F-01205DR) (Word)
Spanish (F-01205DS) (Word)

Participant Education: Program Integrity - Budget Monitoring (F-01205E) (Word)
Hmong (F-01205EH) (Word)
Russian (F-01205ER) (Word)
Spanish (F-01205ES) (Word)

Participant Education: Complaints and Grievances (F-01205F) (Word)
Hmong (F-01205FH) (Word)
Russian (F-01205FR) (Word)
Spanish (F-01205FS) (Word)

Participant Education: Notices of Action and Appeals (F-01205G) (Word)
Hmong (F-01205GH) (Word)
Russian (F-01205GR) (Word)
Spanish (F-01205GS) (Word)

Participant Education: Program Integrity – Conflict of Interest (F-01205i) (Word)
Hmong (F-01205IH) (Word)
Russian (F-01205IR) (Word)
Spanish (F-01205IS) (Word)

IRIS Participant Education – Self-Directed Personal Care (F-01205J) (Word)
Hmong (F-01205JH) (Word)
Russian (F-01205JR) (Word)
Spanish (F-01205JS) (Word)

Participant Education: Annual Health Care Information (F-01205K) (Word)
Hmong (F-01205KH) (Word)
Russian (F-01205KR) (Word)
Spanish (F-01205KS) (Word)

Participant Education: Restrictive Measures (F-01205M) (Word)
Hmong (F-01205MH) (Word)
Russian (F-01205MR) (Word)
Spanish (F-01205MS) (Word)

Participant Education: Background Check Process (F-01205P) (Word)
Hmong (F-01205PH) (Word)
Russian (F-01205PR) (Word)
Spanish (F-01205PS) (Word)

Medical and Remedial Expense Checklist (F-00295) (Word)

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)

Accessibility Assessment (F-01213) (Word)

Cost Share Repayment Agreement (F-01200) (Word)

Fiscal Employer Agent Selection (F-01293) (Word)

Conflict of Interest Disclosure – Participant (F-01310A) (Word)

Risk Agreement - IRIS Program (F-01558)

IRIS Self-Directed Personal Care (SDPC) – My Cares (F-01566) (Word)

IRIS Self-Directed Personal Care (SDPC) – Physician Order & Plan of Care (F-01566A) (Word)

Participant-Hired Worker 40-Hour Health and Safety Assurance Exception Request (F-01689) (Word)

Rights and Responsibilities

Grievance (F-01212) (Word)

Fraud Statement – IRIS Program (F-01261) (Word)

Participant-Hired Worker Specific

Application for Employer Identification Number (FSS-4) (PDF)

Employer/Payer Appointment of Agent (F2678) (PDF)

Background Disclosure (F-82064) (Word)

Background Disclosure Addendum (F-01246) (Word)

Form W-4 (PDF)

Employment Eligibility Verification (I-9) (PDF)

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)

MA Provider Agreement (F-00180B) (Word)

Background Check Appeal Request - IRIS Program (F-01352) (Word)
Hmong (F-01352H) (Word)
Russian (F-01352R) (Word)
Spanish (F-01352S) (Word)

Vendor Specific

Provider Application (F-01312) (Word)

Form W-9 (PDF)

MA Provider Agreement (F-00180, Traditional) (Word)

MA Provider Agreement (F-00180A, Non-Traditional) (Word)

Provider Education: Health and Safety - Incident Reporting (F-01203) (Word)

Agency Specific

IRIS Certification Acknowledgement (F-01209) (Word)

IRIS Consultant Agency Quality Management Plan (F-01208) (Word)

IRIS Consultant Agency Quality Management Plan Tracking (F-01208A) (Excel)

IRIS Fiscal Employer Agent Quality Management Plan (F-01207) (Word)

IRIS Fiscal Employer Agent Quality Management Plan Tracking (F-01207A) (Excel)

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)

Conflict of Interest Disclosure – Provider (F-01310) (Word)

Orientation and Enrollment Checklist (F-01309) (Word)

Employment Checklist (F-01314) (Word)

IRIS Provider Board Member Disclosure (F-01275) (Word)

IRIS Provider Executive Staff Disclosure (F-01275A) (Word)

IRIS Consultant Biography Template (F-01486) (Word)

IRIS Fiscal Employer Agent (FEA) Biography (Template) (F-01545) (Word)

IRIS Consultant Agency (ICA) Biography (Template) (F-01546) (Word)

Provider Reference Sheet – Assignments by Areas of Responsibility (F-01555) (Word)

Guardian Specific

Power of Attorney and Declaration of Representative (F2848) (PDF)

Power of Attorney (F-00036) (PDF)

Last Revised: August 29, 2017