State of wisconsin iris involuntary disenrollment request instructions



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DEPARTMENT OF HEALTH SERVICES

Division of Long Term Care

F-01319 (10/2015)


STATE OF WISCONSIN

IRIS INVOLUNTARY DISENROLLMENT REQUEST




INSTRUCTIONS:

IRIS Consultant Agencies (ICAs) must complete this form to request approval from the Department of Health Services (DHS) to disenroll participants who have meet the criteria for involuntary disenrollment identified in IRIS Work Instruction Manual Section 7.1A.1.

Wisconsin State Statute does not require the completion of this form; however, the IRIS program requires the completion of this form to process requests for the involuntary disenrollment of IRIS participants. Personally identifiable information on this form is collected to correctly identify the participant within the IT system, and will be used only for this purpose.



SECTION I –DEMOGRAPHICS




Participant’s Name (Last, First)

     


Participant’s MCI

     


Target Group

 DD  PD  FE



Participant’s IRIS Consultant Agency

     


Date of Last Face-to-Face Contac t

     


Date of Last Attempted Face-to-Face Contact

     


Date of Last Phone Contact

     


Date of Last Attempted Phone Contact

     


Reason for Disenrollment






No Spend



No Contact



Health and Safety



Residing in an Ineligible Living Setting



Substantiated Fraud



Mismanagement of Budget Authority



Mismanagement of Employer Authority



Refusal to Comply with IRIS Program Requirements

SECTION II – Reason for Request




Provide a detailed explanation of the reason for the request.

     





SECTION III – Explanation of Attempted Mitigation Strategies




Provide a detailed explanation of the mitigation strategies implemented to prevent involuntary disenrollment.

     





SECTION IV – Conclusion




Explain why the mitigation strategies were unsuccessful and involuntary disenrollment is the only option.

     





SECTION IV – APPLICABLE TO NO CONTACT OR NO SPEND ONLY




Date ICA Checked For Alternate Contact Information

     


Date ICA Sent Initial Notification of Need for Contact

     


Date ICA Sent Final Notification of Need for Contact

     


Date of Last IRIS Expenditure

     


My signature indicates that the information provided above is true and accurate to the best of my knowledge.




SIGNATURE – IRIS Consultant Agency Representative

Date Signed











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