IRIS-FSA Forms

Important note:
Appropriate forms must be approved by the participant or the participant's guardian.

Please click on the name of the form to open it.
  

Participant Start-up Forms:

• Participant Checklist
• Form 2678
  • Sample Form 2678
• Form SS-4
  • Instructions for Completing Form SS-4
  • Sample Form SS-4
• Fiscal Agent Information (if applicable)
• Worker's Compensation (optional)
  • Sample Worker's Compensation Form
• If the participant has a guardian or power of attorney, the following forms are required:
  • Guardianship or Power of Attorney Documents
  • Form 56
    • Instructions for Completing Form 56 
    • Form 56 is required if the participant has a guardian.
  • Form 2848
    • Instructions for Completing Form 2848 
    • Form 2848 is required if the participant has a guardian or power of attorney.
  • Form F-00036
    • Form F-00036 is required if the participant needs to assign a power of attorney.

Participant Transit Order Forms:

• Eau Claire Transit Order Form
• GO Transit (Oshkosh) Transit Order Form
• Milwaukee County Transit Order Forms:
  • Bus Tickets
  • Reduced Fare Bus Tickets
  • Monthly Bus Pass
  • Transit Tickets
• Outagamie County Transit Order Form
• Shoreline Metro Transit Order Form
• Valley Transit Order Form
• Washington County Transit Order Form
• Waukesha Metro Transit Order Form
• Wausau Metro Ride Order Form

Other Participant Forms:

• Participant Check Request Form
  • Sample Participant Check Request Form
• Explanation Letter for Vendors
• OSHA Standard Precautions
• Standard Precautions for Bloodborne Transmission
• Confidential Information Release Authorization, required to provide participant information to someone other than the participant or guardian, approved by participant or participant's guardian   
• IRIS-FSA Portal Participant Help Guide

 

Employee Start-up Forms:

• Employee Checklist
• New Employee Set-up Form, approved by participant or participant's guardian
  • Sample New Employee Set-up Form
• Form W-4
  • Sample Form W-4 
  • Form WT-4, required only if claiming exempt on Form W-4
• Form I-9, approved by participant or participant's guardian
  • Sample Form I-9, for help completing the Form I-9
• Copy of signed Social Security Card
• Wisconsin Medicaid Program Provider Agreement (F-00180B), approved by participant or participant's guardian
  • Sample Wisconsin Medicaid Program Provider Agreement
• Background Information Disclosure Addendum
• Background Information Disclosure - English
  • Background Information Disclosure - Hmong
  • Background Information Disclosure - Spanish
• Direct Deposit Authorization Form with voided check or bank verification (optional)
• Employer and Employee Agreement, approved by participant or participant's guardian (optional)    
• Training Documentation Form, approved by participant or participant's guardian (optional) 

Employee Payment Forms:

• 2013 IRIS Time Report Payment Schedule
• Employee Time Report, fillable version
  • Note: you can type all information in this Time Report, but you must print it for the participant or guardian and employee signatures. 
• Employee Time Report, blank version
  • Sample Employee Time Report, for help filling out the Employee Time Report

• Employee Mileage Log, fillable version
  • Note: you can type all information in this Mileage Log, but you must print it for the participant or guardian and employee signatures.
• Employee Mileage Log, blank version 
  • Sample Employee Mileage Log
• Employee Expense Report, fillable version 
  • Note: you can type all information in this Expense Report, but you must print it for the participant or guardian and employee signatures.
• Employee Expense Report, blank version
  • Sample Employee Expense Report

Other Employee Forms:

• Employee Status Change Form, to change employee information
• Rate Change Form, to add a new rate for an employee
• Employee Benefits Program
• Employee Voluntary Dental and Vision
• Permanent Bar from Employment List
• IRIS-FSA Portal Employee Help Guide

Vendor Start-up Forms:

• Vendor Checklist
• Vendor Application   
• License Requirements List
• Form W-9
  • Sample Form W-9
• Wisconsin Medicaid Program Provider Agreement (F-00180, Traditional), approved by participant or participant's guardian OR  
• Wisconsin Medicaid Program Provider Agreement (F-00180A, Non-Traditional), approved by participant or participant's guardian
  • Sample Vendor Wisconsin Medicaid Program Provider Agreement
• Copy of Liability Insurance Certificate
• Copy of Professional License and/or Certificate (if applicable, see License Requirements List)
• Copy of Driver's License (required if providing specialized transportation)
• Provider Agreement, approved by participant or participant's guardian
• Adult Family Home Information Form (required for AFH providers with non-taxable income)
• Vendor Direct Deposit Authorization Form with voided check or bank verification (optional)

Vendor Payment Forms:

• 2013 IRIS Claims Payment Schedule
• Claim Form
  • Sample Claim Form
• Select Field Descriptions for Vendor Claim Form

Rights and Responsibilities:

• Complaints and Grievances
• IRIS Participant Appeal Rights
• Medicaid Waiver Services Summary Definitions
• Participant Rights and Responsibilities Notification

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