IRIS Forms

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Document NameSummaryTags
2022 IRIS Payroll Payment ScheduleIRIS Payroll Payment Schedule. This iLIFE document details the pay period start dates, end dates, due dates, and check dates for IRIS participant-hired worker payments.PPT
IRIS Participant Start-up Packet (blank(fillable) (sampleIRIS Participant Start-up Packet. This iLIFE packet includes all the forms a participant needs to complete to have iLIFE as their FEA.PPT
Participant Reimbursement Request Form (blank) (fillable) (Spanish fillable) (sample) (tips)Participant Reimbursement Request Form. This iLIFE form is used by participants to request expense reimbursement for approved goods.PPT
Participant Payment Election Form (blank) (fillable) (Spanish fillable) (electronic submission)Participant Payment Election Form. Participants complete this iLIFE form to set up direct deposit or an iLIFE pay card.PPT
Form 2678: Employer/Payer Appointment of AgentEmployer/Payer Appointment of Agent. This form is pre-filled for iLIFE as the FEA. It allows the FEA to file returns and make deposits or payments of employment on behalf of the participant employer.PPT
Form SS-4: Application for Employer Identification NumberApplication for Employer Identification Number. This form is pre-filled for iLIFE as the FEA. It is used to apply for an EIN on behalf of the participant employer.PPT
Form 8821: Tax Information AuthorizationTax Information Authorization. This form is pre-filled for iLIFE as the FEA. It authorizes information exchanges between the FEA and IRS.PPT
Participant Fiscal Employer Agent Selection Form (blank) (fillable)Participant Fiscal Employer Agent (FEA) Selection Form. This form is used to indicate the participant's selection of an IRIS Fiscal Employer Agent.PPT
IRIS Participant Employer Handbook: How to be an EmployerIRIS Participant Employer Handbook: How to be an Employer. This iLIFE document provides tips on finding, hiring, and terminating employees.PPT
IRIS Fiscal Employer Agent (FEA) TipsIRIS Fiscal Employer Agent (FEA) Tips. This iLIFE flyer provides information about navigating the IRIS program, including using timesheets, information about various forms, and how to sign up for the iLIFE Portal.PPT
OSHA Standard PrecautionsOSHA Standard Precautions for Your Caregivers. This iLIFE document provides information on finding OSHA guidelines for infection control and disease prevention.PPT
Standard Precautions for Bloodborne TransmissionStandard Precautions for Bloodborne Transmission. This iLIFE document provides general information on preventing bloodborne transmission of disease.PPT
Confidential Information Release Authorization (F-82009)Confidential Information Release Authorization. Completion of this form authorizes the release of information as described on the form.PPT
Portal Participant Help GuideParticipant Portal Help Guide. This guide for participants details how to use iLIFE's IRIS timesheet portal (the iLIFE Portal).PPT
IRIS FEA Transfer CalendarIRIS FEA Transfer Calendar. PPT
IRIS Participant-hired Worker Start-up Packet (blank) (fillable) (sample)IRIS Participant-hired Worker Start-up Packet. This packet includes all the forms a participant-hired worker applicant may need to complete to be an approved service provider in the IRIS program with iLIFE.PHW
Timesheet (blank) (fillable) (Spanish fillable) (sample)Timesheet. Participant-hired workers use this form to detail services provided to a participant in the IRIS program.PHW
Timesheet: In/Out Time (blank) (fillable) (sample)In/Out Timesheet. This iLIFE form is used to detail exact times services were provided by a participant-hired worker to a participant in the IRIS program.PHW
Mileage Log (blank) (fillable) (Spanish fillable) (sample)Mileage Log. Participant-hired workers use this iLIFE form to detail transportation services provided to a participant in the IRIS program.PHW
Expense Report: (blank) (fillable) (sample)Participant-hired Worker Expense Report. This iLIFE form is used by participant-hired workers to request expense reimbursement for approved goods.PHW
Status Change Form (blank) (fillable) (Spanish fillable)Participant-hired Worker Status Change Form. This iLIFE form is used by a participant-hired worker to make changes to their account (such as changes to their name, address, phone, or email), to add a termination date, or to have their check stubs sent to themselves.PHW
Payment Election Form (blank) (fillable) (Spanish fillable) (electronic submission)Participant-hired Worker Payment Election Form. Participant-hired workers complete this iLIFE form to set up direct deposit or an iLIFE pay card.PHW
IRIS Participant-hired Worker Set-up Form (F-01201) - EnglishHmongSpanishIRIS Participant-Hired Worker Set-Up. Both the participant-hired worker and participant employer must sign and date this form for it to be considered complete.PHW
IRIS Participant-hired Worker Relationship Identification (F-01201A) - EnglishHmongSpanish
IRIS Participant-Hired Worker Relationship Identification. Both the participant-hired worker and participant employer must sign and date this form for it to be considered complete.PHW
Form W-4Employee’s Withholding Certificate (for federal tax withholding). This form determines how much is withheld from an employee's paycheck for federal income tax.PHW
Form WT-4Employee's Wisconsin Withholding Exemption Certificate/New Hire Reporting (for state tax withholding). This form determines how much is withheld from an employee's paycheck for Wisconsin income tax.PHW
Form WT-4 IRS Notice 2014-7 FlyerForm WT-4 IRS Notice 2014-7 Flyer. This iLIFE flyer provides information about IRS Notice 2014-7.PHW
IRS Notice 2014-7 Caregiver Exemption FormNotice 2014-7 Caregiver Exemption Statement. Participant-hired workers complete this iLIFE document to declare their caregiver exemption status.PHW
Form I-9Employment Eligibility Verification. This form is used to verify the identity and employment authorization of individuals hired in the United States.PHW
Background Information Disclosure (F-82064) - EnglishHmongSpanishBackground Information Disclosure (BID) for Entity Employees and Contractors. This form captures information used to conduct background checks for individual service providers.PHW
Background Information Disclosure Addendum (F-01246) - EnglishHmongSpanishBackground Information Disclosure Addendum – IRIS. This form captures additional information that may be used (if needed) to conduct background checks for participant-hired worker applicants.PHW
IRIS Participant Employer / Participant-hired Worker Agreement (F-1201C) - EnglishHmongSpanish
IRIS Participant Employer/Participant-hired Worker Agreement. This form captures initial employment agreements made between the participant and participant-hired worker.PHW
Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participant for Waiver Service Provider Agencies (F-00180C)Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals. This form details some agreements and acknowledgements service providers must agree to during the application process.PHW
Employment Verification FormEmployment Verification Request Form. This iLIFE form is used by participant-hired workers to request information regarding their employment history with a participant in the IRIS program.PHW
Unemployment Insurance FAQUnemployment Insurance FAQ. This iLIFE document details frequently asked questions for participant-hired workers in the IRIS program regarding unemployment insurance.PHW
Participant-hired Worker Portal Help GuideParticipant-hired Worker Portal Help Guide. This guide for participant-hired workers details how to use iLIFE's IRIS timesheet portal (the iLIFE Portal).PHW
IRIS Participant-hired Worker Welcome PacketParticipant-hired Worker Welcome Packet. iLIFE sends this packet to participant-hired workers when they are approved to provide services in the IRIS program if iLIFE is their participant's FEA.PHW
Permanent Bar ListThis is a hyperlink to the IRIS Policy Manual.PHW
2022 IRIS Vendor Payment ScheduleIRIS Vendor Payment Schedule. This iLIFE document details the pay period start dates, end dates, due dates, and check dates for IRIS vendor payments.Vendor
2022 IRIS Vendor Transit Ticket ScheduleIRIS Vendor Transit Ticket Schedule. This iLIFE document details when transit ticket requests for a month are due, are mailed, and when they can be picked up. Vendor
IRIS Vendor Start-up Packet (blank) (fillable) (sampleIRIS Vendor Start-up Packet. This iLIFE packet includes all the forms a vendor may need to complete to be an approved service provider in the IRIS program with iLIFE.Vendor
Claim Form (blank) (fillable) (sample) (tips)Claim Form. Vendors use this form to detail services provided to a participant in the IRIS program.Vendor
Vendor Direct Deposit Authorization Form (blank) (fillable) (electronic submission)Vendor Direct Deposit Authorization. Vendors complete this iLIFE form to set up direct deposit.Vendor
Vendor Welcome PacketVendor Welcome Packet. iLIFE sends this packet to vendors when they are approved to provide services in the IRIS program if iLIFE is the participant's FEA.Vendor
Provider Start-up and Requirements ChecklistProvider Start-up and Requirements Checklist. This iLIFE form details what forms a vendor must complete for the application process as a vendor in the IRIS program.Vendor
Provider Application (F-01312)IRIS Provider Application. Completion of this form required to be an approved vendor in the IRIS program.Vendor
Credentialing Requirements ListIRIS Credentialing Requirements List. This iLIFE form lists those occupations/fields that require the vendor supply a copy of their license and/or certificate.Vendor
Form W-9Form W-9. This IRS tax form is used to confirm a vendor's information for tax-filing purposes.Vendor
Sample Form W-9Former W-9. Sample IRS tax form is used to confirm a vendor's information for tax-filing purposes.Vendor
Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participant for Waiver Service Provider Agencies (F-00180C)Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals. This form details some agreements and acknowledgements service providers must acknowledge during the application process.Vendor
License Requirements ListIRIS License Requirements List. This iLIFE form lists those occupations/fields that require the vendor supply a copy of their license and/or certificate.Vendor
Provider Agreement (fillable)Provider Agreement. This iLIFE form should be signed by both the vendor and the participant.Vendor
Adult Family Home Information Form (fillable)Adult Family Home Information Form. This iLIFE form is required for adult family home providers.Vendor
Vendor Income Verification Request (fillable)Vendor Income Verification Request. This iLIFE form is used by vendors to request start date, end date, and wage history information.Vendor
Vendor Status Change Form (fillable)Vendor Status Change Form. This iLIFE form is used by a vendor to make changes to their account, such as changes to address, phone, email, business name, and end date.Vendor
Background Information Disclosure Addendum (F-01246)Background Information Disclosure Addendum – IRIS.This form captures the worker’s previous residences for consideration in the resulting background check. Vendor
Background Information Disclosure (English)Background Information Disclosure (BID) for Entity Employees and Contractors. This form captures information used to conduct background checks for individual service providers.Vendor
Background Information Disclosure (Hmong)Background Information Disclosure (BID) for Entity Employees and Contractors. This form captures information used to conduct background checks for individual service providers.Vendor
Background Information Disclosure (Spanish)Background Information Disclosure (BID) for Entity Employees and Contractors. This form captures information used to conduct background checks for individual service providers.Vendor
Eau Claire Transit Order Form (fillable)Eau Claire Transit Order Form. IRIS participants use this form to order transit service in Eau Claire if their FEA is iLIFE.Transit
Fond du Lac Transit Order Form (fillable)Fond du Lac Transit Order Form. IRIS participants use this form to order transit service in Fond du Lac if their FEA is iLIFE.Transit
GO Transit (Oshkosh) Transit Order Form (fillable)GO Transit (Oshkosh) Transit Order Form. IRIS participants use this form to order transit service in Oshkosh if their FEA is iLIFE.Transit
Green Bay Metro Transit Order Form (fillable)Green Bay Metro Transit Order Form. IRIS participants use this form to order transit service in Green Bay if their FEA is iLIFE.Transit
Kenosha Transit Order Form (fillable)Kenosha Transit Order Form. IRIS participants use this form to order transit service in Kenosha if their FEA is iLIFE.Transit
Madison Metro Transit Order FormMadison Metro Transit Order Form. IRIS participants use this form to order transit service in Madison Metro area.Transit
Maritime Metro (Manitowoc) Transit Order Form (fillable)Maritime Metro (Manitowoc) Transit Order Form. IRIS participants use this form to order transit service in metro Manitowoc area if their FEA is iLIFE.Transit
Milwaukee Bus Tickets Milwaukee Bus Tickets form. IRIS participants use this form to order Milwaukee bus tickets if their FEA is iLIFE.Transit
Milwaukee Reduced Fare Bus Tickets Milwaukee Reduced Fare Bus Tickets form. IRIS participants use this form to order Milwaukee reduced fare bus tickets if their FEA is iLIFE.Transit
Milwaukee Monthly Bus PassMilwaukee Monthly Bus Pass form. IRIS participants use this form to order Milwaukee bus passes if their FEA is iLIFE.Transit
Milwaukee Reduced Fare Monthly Bus PassMilwaukee Reduced Fare Monthly Bus Pass form. IRIS participants use this form to order Milwaukee reduced fare bus passes if their FEA is iLIFE.Transit
Milwaukee Transit TicketsMilwaukee Transit Tickets form. IRIS participants use this form to order Milwaukee paratransit tickets if their FEA is iLIFE.Transit
Outagamie County Transit Order Form (fillable)Outagamie County Transit Order Form. IRIS participants use this form to order transit service in Outagamie County if their FEA is iLIFE.Transit
Ozaukee County Shared Ride Taxi (fillable)Ozaukee County Transit Order Form. IRIS participants use this form to order transit service in Ozaukee County if their FEA is iLIFE.Transit
Racine Transit Order Form (fillable)Racine Transit Order Form. IRIS participants use this form to order transit service Racine if their FEA is iLIFE.Transit
BarabooBaraboo Transit Order Form. IRIS participants use this form to order Running Inc. transit service in Baraboo if their FEA is iLIFE.Transit
Brown CabBrown Cab Transit Order Form. IRIS participants use this form to order Running Inc. transit service in Edgerton, Fort Atkinson, Jefferson, Lake Mills, Medford, Monroe, Ripon, Sauk Prairie, Waupaca, Waupun, and Whitewater if their FEA is iLIFE.Transit
WestbyWesty Transit Order Form. IRIS participants use this form to order Running Inc. transit service in Westby if their FEA is iLIFE.Transit
ViroquaViroqua Transit Order Form. IRIS participants use this form to order Running Inc. transit service in Viroqua if their FEA is iLIFE.Transit
TomahTomah Transit Order Form. IRIS participants use this form to order Running Inc. transit service in Tomah if their FEA is iLIFE.Transit
Sun PrairieSun Prairie Transit Order Form. IRIS participants use this form to order Running Inc. transit service in Sun Prairie if their FEA is iLIFE.Transit
StoughtonStoughton Transit Order Form. IRIS participants use this form to order Running Inc. transit service in Stoughton if their FEA is iLIFE.Transit
River FallsRiver Falls Transit Order Form. IRIS participants use this form to order Running Inc. transit service in River Falls if their FEA is iLIFE.Transit
Richland CenterRichland Center Transit Order Form. IRIS participants use this form to order Running Inc. transit service in Richland Center if their FEA is iLIFE.Transit
Rice LakeRice Lake Transit Order Form. IRIS participants use this form to order Running Inc. transit service in Rice Lake if their FEA is iLIFE.Transit
RhinelanderRhinelander Transit Order Form. IRIS participants use this form to order Running Inc. transit service in Rhinelander if their FEA is iLIFE.Transit
ReedsburgReedsburg Transit Order Form. IRIS participants use this form to order Running Inc. transit service in Reedsburg if their FEA is iLIFE.Transit
Prairie du ChienPrairie du Chien Transit Order Form. IRIS participants use this form to order Running Inc. transit service in Prairie du Chien if their FEA is iLIFE.Transit
PortagePortage Transit Order Form. IRIS participants use this form to order Running Inc. transit service in Portage if their FEA is iLIFE.Transit
PlattevillePlatteville Transit Order Form. IRIS participants use this form to order Running Inc. transit service in Platteville if their FEA is iLIFE.Transit
OnalaskaOnalaska Transit Order Form. IRIS participants use this form to order transit service in Onalaska if their FEA is iLIFE.Transit
New RichmondNew Richmond Transit Order Form. IRIS participants use this form to order Running Inc. transit service in New Richmond if their FEA is iLIFE.Transit
MaustonMauston Transit Order Form. IRIS participants use this form to order Running Inc. transit service in Mauston if their FEA is iLIFE.Transit
MarshfieldMarshfield Transit Order Form. IRIS participants use this form to order Running Inc. transit service in Marshfield if their FEA is iLIFE.Transit
Chippewa FallsChippewa Falls Transit Order Form. IRIS participants use this form to order Running Inc. transit service in Chippewa Falls if their FEA is iLIFE.Transit
Beaver DamBeaver Dam Transit Order Form. IRIS participants use this form to order Running Inc. transit service in Beaver Dam if their FEA is iLIFE.Transit
Shoreline Metro Transit Order Form (fillable)Shoreline Metro Transit Order Form. IRIS participants use this form to order Shoreline Metro transit service if their FEA is iLIFE.Transit
Valley Transit (Appleton) Order Form (fillable)Valley Transit (Appleton) County Transit Order Form. IRIS participants use this form to order Valley Transit service in Appleton if their FEA is iLIFE.Transit
Washington County Transit Order Form (fillable)Washington County Transit Order Form. IRIS participants use this form to order transit service in Washington County if their FEA is iLIFE.Transit
Waukesha Metro Transit Order Form (fillable)Waukesha Metro Transit Order Form. IRIS participants use this form to order transit service in the Waukesha Metro area if their FEA is iLIFE.Transit
Wausau Metro Ride Order Form (fillable)Wausau Metro Transit Order Form. IRIS participants use this form to order transit service in the Wausau Metro area if their FEA is iLIFE.Transit
Door2Door Transit Form
Complaints and Grievances (F-1205F)Other
Grievance Form (F-01212)Grievance - IRIS Program form. This form is used by IRIS participants and/or their representatives to file formal grievances regarding any aspect of the care or service provided by the program and/or its staff members.Other
Fraud Statement - IRIS Program (F-01261)Fraud Statement - IRIS Program form. This form is used to report fraud in the IRIS program.Other
IRIS Participant Appeal Rights (P-00679)IRIS Participant Appeal Rights. This document details how a participant can request a State Fair Hearing to appeal a Notice of Action.Other
IRIS Service Definition Manual (P-00708B)IRIS Service Definition Manual. This document details the long-term care services and supports covered by the IRIS program and the qualifications providers must meet to provide such services and/or supports.Other
Participant Rights and Responsibilities Notification (F-20985)Participant Rights and Responsibilities Notification. This document details those rights granted to an applicant/participant of the CLTS Waiver Program.Other
W-2 Reprint Request FormOther
Beaver DamBeaver Dam Transit Order Form. IRIS participants use this form to order Running Inc. transit service in Beaver Dam if their FEA is iLIFE.Transit
Shoreline Metro Transit Order Form (fillable)Shoreline Metro Transit Order Form. IRIS participants use this form to order Shoreline Metro transit service if their FEA is iLIFE.Transit
Valley Transit (Appleton) Order Form (fillable)Valley Transit (Appleton) County Transit Order Form. IRIS participants use this form to order Valley Transit service in Appleton if their FEA is iLIFE.Transit
Washington County Transit Order Form (fillable)Washington County Transit Order Form. IRIS participants use this form to order transit service in Washington County if their FEA is iLIFE.Transit
Waukesha Metro Transit Order Form (fillable)Waukesha Metro Transit Order Form. IRIS participants use this form to order transit service in the Waukesha Metro area if their FEA is iLIFE.Transit
Wausau Metro Ride Order Form (fillable)Wausau Metro Transit Order Form. IRIS participants use this form to order transit service in the Wausau Metro area if their FEA is iLIFE.Transit
ICA One-Pager Order FormOther
ICA One-Pager Order Form - Dane CountyOther
Complaints and Grievances (F-1205F)Other
Grievance Form (F-01212)Grievance - IRIS Program form. This form is used by IRIS participants and/or their representatives to file formal grievances regarding any aspect of the care or service provided by the program and/or its staff members.Other
Fraud Statement - IRIS Program (F-01261)Fraud Statement - IRIS Program form. This form is used to report fraud in the IRIS program.Other
IRIS Participant Appeal Rights (P-00679)IRIS Participant Appeal Rights. This document details how a participant can request a State Fair Hearing to appeal a Notice of Action.Other
IRIS Service Definition Manual (P-00708B)IRIS Service Definition Manual. This document details the long-term care services and supports covered by the IRIS program and the qualifications providers must meet to provide such services and/or supports.Other
Participant Rights and Responsibilities Notification (F-20985)Participant Rights and Responsibilities Notification. This document details those rights granted to an applicant/participant of the CLTS Waiver Program.Other
W-2 Reprint Request FormOther

Start-Up Forms
◾ IRIS Participant Start-up Packet (blank) (fillable) (sample
◾ Participant Reimbursement Request Form (blank) (fillable) (Spanish fillable) (sample) (tips)
◾ Participant Payment Election Form (blank) (fillable) (Spanish fillable) (electronic submission)
Form 2678: Employer/Payer Appointment of Agent
Form SS-4: Application for Employer Identification Number
Form 8821: Tax Information Authorization
◾ Participant Fiscal Employer Agent Selection Form (blank) (fillable)
Note: Voided check or typed bank verification must be attached If the participant has a guardian or power of attorney, the following forms are required: Guardianship or Power of Attorney Document
Form 2848: Power of Attorney and Declaration of Representative
Note: Form 2848 is required if the participant has a guardian or power of attorney
Form F-00036: Wisconsin Power of Attorney for Finances and Property
Note: Form F-00036 is required if the participant needs to assign a power of attorney.

Other
Participant Fiscal Employer Agent (FEA) Selection Form (fillable)
◾ Participant Reimbursement Request Form (blank) (fillable) (Spanish fillable) (sample) (tips)
IRIS Participant Employer Handbook: How to be an Employer
IRIS Fiscal Employer Agent (FEA) Tips
OSHA Standard Precautions
Confidential Information Release Authorization (F-82009)
Note: Required to provide participant information to someone other than the participant or guardian
Note: Must be approved by participant or participant’s guardian
Portal Participant Help Guide
2021-2022 IRIS FEA Transfer Calendar

Start-Up Forms
◾ IRIS Participant-hired Worker Start-up Packet (blank) (fillable) (sample)
Participant-hired worker Welcome Packet
◾ IRIS Participant-hired Worker Relationship Identification (F-01201A) – EnglishHmongSpanish
Note: Approved by participant or participant’s guardian
IRIS Participant-hired Worker Relationship Identification
◾ (F-01201A) – English, Hmong, Spanish
Note: Approved by participant or participant’s guardian
Form W-4
Form WT-4
IRS Notice 2014-7 Flyer
IRS Notice 2014-7 Caregiver Exemption Form
Form I-9 (Use this link if on a mobile device)
The direct link to this form on the USCIS website is here. You can only open the form via this link on a laptop/desktop computer, not via a mobile device. 

To open, please follow these instructions:
Click the link and download the PDF to your computer. 
Right click on the file name and choose “Open with System Viewer”
Note: Approved by participant or participant’s guardian
◾ Background Information Disclosure (F-82064) – English, Hmong, Spanish
◾ Background Information Disclosure Addendum (F-01246) – English, Hmong, Spanish
◾ IRIS Participant Employer / Participant-hired Worker Agreement (F-1201C) – English, Hmong, Spanish
Note: Approved by participant or participant’s guardian
Note: Approved by participant or participant’s guardian
◾ Payment Election Form (blank) (fillable) (Spanish fillable) (electronic submission)
Note: Voided check or typed bank verification must be attached for Direct Deposit option.
◾ IRIS Participant-hired Worker Start-up Packet (blank) (fillable) (sample)
Status Change Form (blank) (fillable) (Spanish fillable)
Employment Verification Form
Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participant for Waiver Service Provider Agencies (F-00180C)

Payment Forms
IRIS Payment Schedule
◾ Timesheet (blank) (fillable) (Spanish fillable) (sample) (tips)
◾ Timesheet: In/Out Time (blank) (fillable) (sample)
◾ Mileage Log (blank) (fillable) (Spanish fillable) (sample)
◾ Expense Report: (blank) (fillable) (sample)

2022 IRIS Vendor Payment Schedule
2022 IRIS Vendor Transit Ticket Schedule
◾ IRIS Vendor Start-up Packet (blank) (fillable) (sample
IRIS Vendor Welcome Packet
IRIS Vendor Set-up Tips
◾ Vendor Income Verification Request (fillable)
◾ Vendor Status Change Form (fillable)
Provider Start-up and Requirements Checklist
Provider Application (F-01312)
Credentialing Requirements List
Form W-9 Sample Form W-9
Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participant for Waiver Service Provider Agencies (F-00180C)
Copy of Liability Insurance Certificate
Copy of Professional License and/or Certificate
Note: If applicable, see License Requirements List
Copy of Driver’s License
Note: Required if providing specialized transportation
Provider Agreement (fillable)
Note: Approved by participant or participant’s guardian
Adult Family Home Information Form (fillable)
Note: Required for AFH providers with non-taxable income
◾ Vendor Direct Deposit Authorization Form (blank) (fillable) (electronic submission)
Note: Voided check or typed bank verification must be attached
Background Information Disclosure Addendum (F-01246)
Background Information Disclosure (English)
Background Information Disclosure (Hmong)
Background Information Disclosure (Spanish)

Claim Form (blank) (fillable) (sample) (tips)