DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Medicaid Services F-01201 (02/2017) IRIS PARTICIPANT- HIRED WORKER SET- UP INSTRUCTIONS: Completion of this form is not required through Wisconsin State Statute; however, completion of this form is an IRIS Program requirement. Both the participant-hired worker and the participant employer must sign and date the bottom in order to be considered complete. A participant-hired worker may not begin working for a participant before the IRIS start date, indicated in the start date letter. participant’s Personally identifiable information on this form is collected to verify that the application is complete, and will be used only for this purpose. Completed forms should be submitted to the Fiscal Employer Agent. participant’s SECTION I PARTICIPANT-HIRED WORKER DEMOGRAPHICS (all fields must be filled) – Name Participant-Hired Worker (Last, First, MI) Gender Date of Birth – Male Female Mailing Address City Phone Number State Zip Email Address SECTION II PARTICIPANT EMPLOYER DEMOGRAPHICS (all fields must be filled) – Name Participant Employer (Last, First, MI) Date of Birth Master Client Index (MCI) – Mailing Address City Phone Number State Zip Email Address By signing below, I (we) agree the information on this form is accurate and I (we) have all supporting documentation in my possession. Both signers agree to only submit time reports within the hours authorized. Without prior approval, excess hours claimed above the authorization may be rejected for payment. Both signers also acknowledge that no hours worked prior to a passed background check will be authorized. SIGNATURE Participant Hired-Worker Date Signed – SIGNATURE Participant Employer Date Signed –
DEPARTMENT OF HEALTH SERVICES Division of Medicaid Services F-01201 (02/2017) STATE OF WISCONSIN IRIS PARTICIPANT- HIRED WORKER SET- UP INSTRUCTIONS: Completion of this form is not required through Wisconsin State Statute; however, completion of this form is an IRIS Program requirement. Both the participant-hired worker and the participant employer must sign and date the bottom in order to be considered complete. A participant-hired worker may not begin working for a participant before the IRIS start date, indicated in the participant’s start date letter. Personally identifiable information on this form is collected to verify that the application is complete, and will be used only for this purpose. Completed forms should be submitted to the participant’s Fiscal Employer Agent. SECTION I – PARTICIPANT-HIRED WORKER DEMOGRAPHICS (all fields must be filled) Name – Participant-Hired Worker (Last, First, MI) Gender Male Female Date of Birth Mailing Address City Phone Number State Zip Email Address SECTION II – PARTICIPANT EMPLOYER DEMOGRAPHICS (all fields must be filled) Name – Participant Employer (Last, First, MI) Date of Birth Master Client Index (MCI) Mailing Address City Phone Number State Zip Email Address By signing below, I (we) agree the information on this form is accurate and I (we) have all supporting documentation in my possession. Both signers agree to only submit time reports within the hours authorized. Without prior approval, excess hours claimed above the authorization may be rejected for payment. Both signers also acknowledge that no hours worked prior to a passed background check will be authorized. SIGNATURE – Participant Hired-Worker Date Signed SIGNATURE – Participant Employer Date Signed
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