Division of Long Term Care
F-00075 (04/2012) / STATE OF WISCONSIN
IRIS (include, respect, I self-Direct)
referral / authorization
Completing and signing this form is voluntary, however no referral to the IRIS Program can be processed without the completed signed form. ADRC staff completes except when the county support and service coordinator/care manager makes referrals to the IRIS Consultant Agency (ICA) during county Long Term Care (LTC) transition.
The IRIS (Include, Respect, I Self Direct) Referral / Authorization form (F-00075) has multiple functions and must accompany all referrals to the IRIS Program. All information entered must be complete and accurate.
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I. REFERRAL INFORMATION— The referral agent (ADRC or County Staff) completes all boxes in this section. Providing this participant specific information assists the IRIS Consultant Agency to successfully support the participant in IRIS.Date – Consultant Agency granted read access to LTCFS / Date – Referral to ICA and information entered into PPS
Participant Information
Name (Last, First, MI) / Date of Birth / County of Residence
Address / City / Zip Code
Telephone Number / E-mail Address / Best time to contact
Established Guardianship YesNo
Activated Power of Attorney Yes No / Name – Guardian / POA Contact
Telephone Number – Guardian / POA / Best Time to Contact
Special Instructions (e.g., language interpreter needed, unique circumstances)
Medicaid Eligibility Established
Yes No Pending / Annual Medicaid Eligibility Date / Medicare or Other Insurance
Yes No
Monthly Cost Share Amount / IRIS Monthly Allocation
$ / (enter 0 if no cost share) / $ / (as noted in LTCFS)
Monthly Spenddown Amount
$ / (enter 0 if no spenddown)
Person is currently enrolled in (check only one)
Children’s Waiver (CLTS) / HCB Waiver (COP-W, CIP, BIW)
Waitlist / No Prior Program / SSI Managed Care
Family Care / Partnership MCO—Specify MCO Name: / Care Wisconsin First, Inc.Community Care of Central WisconsinCommunity Care, Inc.Community Health PartnershipiCareLakeland Care DistrictMilwaukee County Department of Family CareNorthern BridgesSouthwest Family Care AllianceWestern Wisconsin Cares
Other Pertinent Information(Check all that apply)
In need of immediate services / Has a protective placement
Currently served by CSP / Relocation / currently living in institutional setting (NH, IMD, etc.)
Other—specify:
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F-00075IRIS Referral / AuthorizationPage 2 of 2
Name - Participant (Last, First, MI)II. IRIS RELEASE OF INFORMATION—The referral agent (ADRC or County Staff) completes Section II. Section II secures participant authorization for the IRIS referral and also obtains participant authorization for the referral agent to share the specified participant confidential information with the IRIS Consultant Agency. The referral agent reviews all information, checks each box as information is shared with the participant. The participant / representative affixes his / her signature and the date of the signature as indicated. The referral agent affixes their signature to the right of the participant / representative signature date as indicated. Upon completion, this form, along with any other required information is sent via facsimile to the IRIS Consultant Agency at: (608) 255-0898.
I am interested in considering becoming an IRIS Waiver participant. I understand I will have the opportunity to meet with a consultant from IRIS who will provide me with additional information about IRIS.
I understand that a referral to the IRIS Consultant Agency is not a commitment to enroll in the IRIS program.
I or my representative may withdraw from IRIS at any time upon request.
I authorize that the IRIS Consultant Agency be given access to the following information to help me enroll in IRIS:
Access to my Long Term Care Functional Screen (LTCFS) information
Copy of my CARES screen (identifies cost shares and financial eligibility)
Medical remedial expense details (as needed)
Current copy of my ISP / member centered plan (if applicable and available)
Medical documentation
Other – Specify:
SIGNATURE – Interested Person / Authorized Representative / Date Signed / SIGNATURE – ADRC / CountyStaff
III. INFORMATION COMPLETED BY
Name – ADRC
Name – ADRC Worker completing form / County
Telephone Number / E-mail Address
Referral Entered into PPS Yes
Copy of Referral Form Sent to MFP Yes