Wisconsin IRIS Forms

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Important Notes:

• Appropriate forms must be approved by the participant or the participant's guardian.
• If the participant has a guardian or power of attorney, forms 2848 and F-00036 are required.

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NEW 2018 Forms and Information

Participant and Participant-hired Worker

• 2018 IRIS Payroll Payment Schedule - New for 2018!

Vendor

• 2018 IRIS Vendor Payment Schedule - New for 2018!

Transit

• 2018 IRIS Vendor Transit Ticket Schedule - New for 2018!

Quick Reference Documents

Participant-hired Worker

• IRIS Participant-hired Worker Start-up Packet (blank) (fillable) (sample)
• Timesheet (blank) (fillable) (sample)
• Mileage Log (blank) (fillable) (sample)
• Status Change Form (blank) (fillable)
• Payment Election Form (blank) (fillable) (electronic submission)

Participant

• IRIS Participant Start-up Packet (blank) (fillable) (sample) 
• Participant Reimbursement Request Form (blank) (fillable) (sample) (tips)
• Participant Payment Election Form (fillable) (electronic submission)

Vendor

• IRIS Vendor Start-up Packet (blank) (fillable) (sample) 
• Claim Form (blank) (fillable) (sample) (tips)
• Vendor Direct Deposit Authorization Form (fillable) (electronic submission)

Participant Forms

Start-up Forms

• Form 2678: Employer/Payer Appointment of Agent
• Form SS-4: Application for Employer Identification Number
• Form 8821: Tax Information Authorization
• Participant Payment Election Form (fillable) (electronic submission)
  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
• IRIS Participant Start-up Packet (blank) (fillable) (sample)

Transit Order Forms

• Door County Transit Order Form (fillable)
• Eau Claire Transit Order Form (fillable)
• Fond du Lac Transit Order Form (fillable)
• GO Transit (Oshkosh) Transit Order Form (fillable)
• Green Bay Metro Transit Order Form (fillable)
• Kenosha Transit Order Form (fillable)
• Maritime Metro (Manitowoc) Transit Order Form (fillable)
• Milwaukee County Transit Order Forms:
  • Bus Tickets (fillable)
  • Reduced Fare Bus Tickets (fillable)
  • Monthly Bus Pass (fillable)
  • Transit Tickets (fillable)
• Outagamie County Transit Order Form (fillable)
• Ozaukee County Shared Ride Taxi (fillable)
• Racine Transit Order Form (fillable)
• Running, Inc. Pre-Purchased Punch Card Order Forms
  • Baraboo
  • Beaver Dam
  • Chippewa Falls
  • Edgerton
  • Fort Atkinson
  • Jefferson
  • Lake Mills
  • Marshfield
  • Mauston
  • Medford
  • Monroe
  • New Richmond
  • Onalaska
  • Platteville
  • Portage
  • Prairie du Chien
  • Rice Lake
  • Richland Center
  • Ripon
  • River Falls
  • Sauk Prairie
  • Viroqua
  • Waupaca
  • Waupun
  • Westby
  • Whitewater
• Shoreline Metro Transit Order Form (fillable)
• Valley Transit (Appleton) Order Form (fillable)
• Washington County Transit Order Form (fillable)
• Waukesha Metro Transit Order Form (fillable)
• Wausau Metro Ride Order Form (fillable)
• 2018 IRIS Vendor Transit Ticket Schedule - New for 2018!

Other Participant Documents

• Participant Fiscal Employer Agent (FEA) Selection Form (fillable)
• Participant Reimbursement Request Form (fillable)
  • Sample Participant Reimbursement Request Form
  • Participant Reimbursement Request Tips
• IRIS Participant Employer Handbook: How to be an Employer
• IRIS Fiscal Employer Agent (FEA) Tips
• OSHA Standard Precautions
• Standard Precautions for Bloodborne Transmission
• 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

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Participant-hired Worker Forms

Start-up Forms

• IRIS Participant-hired Worker Set-up Form (F-01201)
  Note: Approved by participant or participant's guardian
• IRIS Participant-hired Worker Relationship Identification (F-01201A)
  Note: Approved by participant or participant's guardian
• Form W-4
  • Form WT-4
    Note: Form WT-4 for the State of Wisconsin withholding is required if you are claiming exempt or if you are claiming a different exemption on your Wisconsin State Taxes than on your Federal Form W-4.
• 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
• Wisconsin Medicaid Program Provider Agreement (F-00180B)
• Background Information Disclosure Addendum (F-01246)
• Background Information Disclosure (English)
• Background Information Disclosure (Hmong)
• Background Information Disclosure (Spanish)
• IRIS Participant Employer / Participant-hired Worker Agreement (F-1201C)
  Note: Approved by participant or participant's guardian
• Training Verification Form (F-01201B)
  Note: Approved by participant or participant's guardian
• Payment Election Form (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)

Payment Forms

• Timesheet: (blank) (fillable) (sample with Timesheet Tips Flyer)
• Timesheet: In/Out Time (blank) (fillable) (sample)
• Mileage Log: (blank) (fillable) (sample)
• Expense Report: (blank) (fillable) (sample)
• IRIS Payroll 2018 Payment Schedule

Other Participant-hired Worker Documents

• Status Change Form (fillable)
  Note: To change participant-hired worker's information, cancel direct deposit or provide termination date
• ​Rate Change Form (fillable) (sample)
  Note: To add or change rates for a  participant-hired worker
• Employment Verification Form
• Permanent Bar from Employment List
• Unemployment Insurance FAQ
  Note: This document explains unemployment insurance and eligibility
• Participant-hired Worker Portal Help Guide
• IRIS Participant-hired Worker Welcome Packet

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Vendor Forms

Start-up Forms

• 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-00180)
• Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Individual or Non-Traditional Providers (F-00180A)
• 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 (fillable) (electronic submission)
  Note: Voided check or typed bank verification must be attached
• Vendor Verification Request (fillable)
• Vendor Status Change Form (fillable)
• Background Information Disclosure Addendum (F-01246)
• Background Information Disclosure (English)
• Background Information Disclosure (Hmong)
• Background Information Disclosure (Spanish)
• IRIS Vendor Start-up Packet (blank) (fillable) (sample)
• IRIS Vendor Set-up Tips

Payment Forms

• Claim Form (fillable) / Claim Form (blank)

  • Sample Claim Form
  • Vendor Claims Tips
• IRIS 2018 Vendor Payment Schedule

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IRIS Consultant Forms

• ICA One-Pager Order Form

Rights and Responsibilities

• Complaints and Grievances (F-1205F)
• Grievance Form (F-01212)
• Fraud Statement - IRIS Program (F-01261)
• IRIS Participant Appeal Rights (P-00679)
• IRIS Service Definition Manual (P-00708B)
• Participant Rights and Responsibilities Notification (F-20985)

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Miscellaneous

• Tips for Sending Timesheets to iLIFE
• Instructions for Faxing Timesheets to iLIFE
• Instructions for Sending Documents to iLIFE
• Portal Help Guide: Participant / Participant-hired Worker
• Unemployment Insurance FAQ

iLIFE Financial Management Services
6100 North Baker Road
Glendale, WI 53209