IRIS FSA Handbook and Forms

|Handbook |Participant Start Up | Vendor Start Up | Vendor Payment | Employee Start Up |
| Employee Payment | AFH Provider Start-up | AFH Provider Payment |

Important note:
ALL APPROPRIATE FORMS MUST BE SIGNED.

Handbook

Participant Start-Up Forms:
• Participant Checklist
• IRS Form 2678 with copy of Guardianship or POA papers
• IRS Form 8821
• Worker’s Compensation (optional form)
• 2009 Payroll & Payment schedule
• 2010 Payroll & Payment schedule
• Participant Check Request Form
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Vendor Start-Up Forms:
• Vendor Checklist
• Explanation To Vendors
• Medicaid Provider Agreement
• W-9
• Provider Agreement, signed by Participant (optional form)
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Vendor Payment Forms:
• State Approved Invoice Form
• 2010 Payroll & Payment schedule
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Employee Start-Up Forms:
• Employee Checklist
• Medicaid Provider Agreement, signed by Participant
• Employee New Hire/Status Change, signed by Participant
• I-9 Eligibility, signed by Participant
• W-4
• Copy of Social Security card
• Background Check Information and Release
• Background Information Disclosure
• Direct Deposit with voided check (optional form)
• Employer & Employee Agreement, signed by Participant (optional form)
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Employee Payment Forms:
• Employee Time Report, signed by Participant and Employee
• 2009 Payroll & Payment schedule
• 2010 Payroll & Payment schedule
• Mileage Spreadsheet
• Expense Reports
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Exempt AFH Provider Start-up Forms:
• AFH Checklist
• Medicaid Provider Agreement
• W-9
• Copy of AFH Certification
• Provider Agreement, signed by Participant (optional form)
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Exempt AFH Provider Payment Forms:
• AFH Billing Form
• 2009 Payroll & Payment schedule
• 2010 Payroll & Payment schedule
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