Wisconsin's Self-Directed Supports Program
Handbooks and Forms
Handbooks | Participant | Vendor | Employee | Substitute Care Facilities | Transit Ticket Forms | Miscellaneous | Rights and Responsibilities
Participant (checklist
)
Employee (checklist)
Vendor (checklist)
Substitute Care Facilities (checklist)
Adobe® Reader® 8.0 or higher may be necessary to view some of these forms. To update your software download Adobe® Reader® X.
Participant (checklist
)
Startup Forms
- Form 2678: Employer/Payer Appointment of Agent
(with copy of Guardianship or POA papers) - Form SS-4: Employer Identification Number
- Information for the Fiscal Intermediary
- IRIS Employee Wage Adjustment Guideline
- Notice: Startup Documents
- Worker's Compensation Insurance (optional)
Payment Forms
Employee (checklist
)
Startup Forms
- Background Check Information and Release
- Background Information Disclosure
- Direct Deposit Authorization (optional)
- Employee New Hire/Status Change, signed by participant
- Employer and Employee Agreement, signed by participant (optional)
- Form I-9 Eligibility, signed by participant
- Form W-4: Employee's Withholding Allowance Certificate
- New Hire Brochure
- OSHA Standard Precautions
- Permanent Bar from Employment as a Caregiver List
- Social Security Card (copy)
- Standard Precaution for Bloodborne Transmission
- Training Document for Hired Workers
- Voluntary Dental and Vision (optional)
- Wisconsin Medicaid Self-Directed Supports Provider Agreement
Payment Forms
Vendor (checklist
)
Startup Forms
- Accessibility Assessment Request Form
- Explanation To Vendors
- Form W-9: Request for Taxpayer Identification Number and Certification
- Proof of License/Certification: Health and Business Professions
- Provider Agreement – signed by participant (optional)
- Wisconsin Medicaid Self-Directed Supports Provider Agreement
Payment Forms
Substitute Care Facilities (checklist
)
Startup Forms
- Copy of Certification / Licensure
- Form W-9: Request for Taxpayer Identification Number and Certification
- Provider Agreement – signed by participant (optional)
- Wisconsin Medicaid Self-Directed Supports Provider Agreement
Payment Forms
Adobe® Reader® 8.0 or higher may be necessary to view some of these forms. To update your software download Adobe® Reader® X.
© 2012 Created by IRIS Webmaster.
