№ files_lp_3_process_9_39755
File format: docx Character count: 1923 File size: 34 KB
Administrative Medicaid program form issued by the Wisconsin Department of Health Services for IRIS Consultant Agencies to request approval for the involuntary disenrollment of program participants based on specified statutory and program criteria.
Country: United States
State: Wisconsin
Issuing Body: Department of Health Services, Division of Medicaid Services
Program: IRIS (Include, Respect, I Self-Direct)
Form Number: F-01319
Edition Date: 02/2017
Document Type: Administrative request form
Subject: Involuntary disenrollment of IRIS participants
Legal Reference: Wisconsin State Statute; IRIS Work Instruction Manual Section 7.1A.1
Target Group: IRIS Consultant Agencies (ICAs)
Applicable Reasons 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
Sections: Demographics; Reason for Request; Explanation of Attempted Mitigation Strategies; Conclusion; Applicable to No Contact or No Spend Only
Signature Requirement: IRIS Consultant Agency Representative
Personal Data: Participant’s name, MCI, contact history, expenditure information
Price: 8 / 10 USD
The file will be delivered to the email address provided at checkout within 12 hours.

Don’t have cryptocurrency yet?

You can still complete your purchase in a few minutes:
  1. Buy Crypto in a trusted app (Coinbase, Kraken, Cash App or any similar service).
  2. In the app, tap Send.
  3. Select network, paste our wallet address.
  4. Send the exact amount shown above.
After sending, paste your TXID (transaction ID) and your email to receive the download link. Need help? Contact support and we’ll guide you step by step.

The final amount may vary slightly depending on the payment method.
The file will be sent to the email address provided at checkout within 24 hours.
The product description is provided for reference. Actual content and formatting may differ slightly.
Consumer Choice Form for Mental Health Rehabilitation Services (MHRS) Core Service Agency Enrollment, Transfer, and Disenrollment
Year: Not specified
Region / City: District of Columbia
Topic: Mental Health Services
Document Type: Form
Organization / Institution: Government of the District of Columbia, Department of Behavioral Health
Author: Not specified
Target Audience: Adults seeking Mental Health Rehabilitation Services
Effective Period: Not specified
Approval Date: Not specified
Modification Date: Not specified
Family Care, PACE, Partnership, and IRIS Program Requested Disenrollment
Year: 2025
Region / City: Wisconsin
Topic: Health Services
Document Type: Form
Organization: Department of Health Services, Division of Public Health
Author: Department of Health Services
Target Audience: Managed Care Organizations, IRIS Consultant Agencies, PACE Organizations, Bureau of Quality & Oversight
Period of Effectiveness: N/A
Approval Date: N/A
Amendment Date: N/A
Contextual Description: Form used by organizations to request disenrollment from the Family Care, PACE, Partnership, and IRIS programs in Wisconsin.
Waiver Program Disenrollment Request
Year: 2023
Region / City: New Jersey
Topic: Disenrollment from DDD Programs
Document Type: Request Form
Institution: Division of Developmental Disabilities (DDD)
Author: DDD Support Coordinator
Target Audience: Individuals enrolled in DDD programs, legal guardians, DDD staff
Effective Period: Not specified
Approval Date: Not specified
Date of Modifications: Not specified
Qualified Health Home Lead Requested Disenrollment – Involuntary
Year: Not specified
Region / City: Not specified
Subject: Involuntary disenrollment from the Health Home program
Document Type: Procedure/Guideline
Organization / Institution: Not specified
Author: Not specified
Target Audience: Health Home Care Coordinators, Lead
Effective Period: Not specified
Approval Date: Not specified
Date of Changes: Not specified
Contextual Description: Procedure for handling involuntary disenrollment from the Health Home program due to beneficiary behaviors or environmental concerns.
TRICARE Prime Enrollment, Disenrollment, and PCM Change Form
Year: 2016
Region: United States and Overseas
Subject: Health Care Enrollment and Management
Document Type: Government Form
Agency: Department of Defense
Author: Defense Health Agency
Intended Audience: Active duty service members, retirees, and eligible family members
Effective Period: Ongoing until updated
Approval: OMB No. XXXX-XXXX
Previous Edition: Obsolete
Form Number: DD Form 2876-3
Application Methods: Online, Telephone, Paper Submission
Privacy Regulations: HIPAA, 10 U.S.C. 1079 and 1086, 38 U.S.C. Chapter 17
Topics: F-01319 022017 Disenrollment