Health Services Service Providers
Resume:
DEPARTMENT OF HEALTH SERVICES
Division of Medicaid Services
F-01312 (12/2022)
STATE OF WISCONSIN
IRIS PROVIDER APPLICATION
INSTRUCTIONS:
Completion of this form is not required through Wisconsin State Statute; however, completion of this form is an IRIS program requirement. Applicants will not be considered as IRIS program service providers until all necessary paperwork is completed, submitted, and verified.
Agency Provider is defined as entities whose employees furnish the service or from which goods are purchased.
Individual Provider is defined as a person who is in an independent practice and not employed by a provider agency.
Personally identifiable information on this form is collected to verify that the application is complete and accurate, and will be used only for this purpose.
PROVIDER DEMOGRAPHICS
Organization Name
Organization Name
Provider’s Name (Last, First, MI)
Last, First, MI
Phone Number
Phone Number
Email Address May be published in Provider Directory
Email Address
Title
Title
Are you applying as (choose one):
Agency Provider
Individual Provider
Type of Application:
Initial Application
Reinstatement
W-9 Name (as shown on income tax return)
W-9
W-9 Business Name (if different from W-9 name)
Click here to enter text.
W-9 Exempt:
Yes
No
State of Wisconsin Department of Financial Institutions ID Number: ID Number
BILLING AND CLAIMS CONTACT INFORMATION
Check all that apply:
Primary Office
Mailing Address
Billing Address
National Provider Identifier (if applicable): NPI
Wisconsin Provider Management Identifier (if applicable): WPMI
Tax Identification Number: EIN/SSN
Tax Qualifier:
EIN
SSN
Organization Name
Organization Name
Name – Contact Person
Contact Person
Phone Number
Phone Number
Email Address May be published in Provider Directory
Email Address
Fax Number
Fax Number
Internet Address May be published in Provider Directory
Web Address
Address
Address
City
City
State
State
Zip Code
Zip Code
County
County
RENDERING PROVIDER CONTACT INFORMATION
Check all that apply:
Primary Office
Mailing Address
Billing Address
National Provider Identifier (if applicable): NPI
Wisconsin Provider Management Identifier (if applicable): WPMI
Tax Identification Number: EIN/SSN
Tax Qualifier:
EIN
SSN
Organization Name
Organization Name
Name – Contact Person
Contact Person
Phone Number
Phone
Email Address May be published in Provider Directory
Email Address
Fax Number
Fax Number
Internet Address May be published in Provider Directory
Web Address
Address
Address
City
City
State
State
Zip Code
Zip Code
County
County
DAILY OPERATIONS CONTACT INFORMATION
Check all that apply:
Primary Office
Mailing Address
Billing Address
National Provider Identifier (if applicable): NPI
Wisconsin Provider Management Identifier (if applicable): WPMI
Tax Identification Number: EIN/SSN
Tax Qualifier:
EIN
SSN
Organization Name
Organization Name
Name – Contact Person
Contact Person
Telephone Number
Phone
Email Address May be published in Provider Directory
Email Address
Fax Number
Fax Number
Internet Address May be published in Provider Directory
Web Address
Address
Address
City
City
State
State
Zip Code
Zip Code
County
County
SERVICES TO BE PROVIDED: List the service(s) you wish to provide. Please reference the IRIS Service Definition Manual for a complete list of allowable services.
Services
Does this service require a license or certification?
Services
License/Cert. Required?
Services
License/Cert. Required?
Services
License/Cert. Required?
LICENSING/CERTIFICATION: List all current licenses and certificates (if applicable). A copy of each is required with this application.
Title of Licensure/Certification
Type of Licensure/Certification
Licensure/Certification Number
State in which Licensure/Certification Obtained
Expiration Date
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By signing below, I certify that background checks on all employees have been completed in accordance with the Wisconsin Caregiver Program.
If I am to provide specialized transportation, I certify that the vehicle used is and will be mechanically sound, has properly functioning lighting, safety, ventilation, and braking systems, and properly inflated tires without excessive wear. I further certify that proper licensing and insurance has been verified and is attached.
I understand and agree that this application will not be processed until it is deemed complete by DHS. It is my responsibility to provide a complete application. I understand and agree that the burden of producing adequate information in a timely manner and for resolving doubts is my responsibility.
I certify that the information in this document and all attached documents is true, correct, and complete. I understand and agree that any misrepresentation, misstatement, or omission from this application, if discovered after provider approval has been awarded, may lead to suspension or termination of provider approval.
SIGNATURE – Provider
Date Signed
Please submit this application to your Fiscal Employer Agent (FEA) using ONE of the following methods:
AGENCY
FAX
GROUND MAIL
GT Independence
ad4v5o@r.postjobfree.com
215 Broadus St.
Sturgis, MI 49091
iLIFE
ad4v5o@r.postjobfree.com
2020 W Wells St
Milwaukee, WI 53233
Outreach Health Services
ad4v5o@r.postjobfree.com
204 3rd Avenue, Suite 110
P.O. Box 945
Osceola, WI 54020
Premier Financial Management Services
ad4v5o@r.postjobfree.com
10425 W North Ave, Suite 345
Milwaukee, WI 53226
Information contained in email messages may be privileged and confidential. There is some risk that any information in an email you send may be disclosed to, or intercepted by, unauthorized third parties. By agreeing to allow the use of email as a method of communication to WI DHS, this indicates that you acknowledge and accept the possible risks associated with such communication.
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