Orion ISO Individualized Home Supports (IHS) Enrollment Packet Request
For questions, please contact HR at 612-400-6412 or isohr@orionassoc.net
Important Notes:
Completed submissions route to HR who will prepare the packet and send to the Employee
In the Individualized Home Supports (IHS) program, Orion ISO is the
Employer
Packet Information
Select the type of Individualized Home Supports (IHS) packet needed
*
Regular packet
Parent packet
It's Working (IW) packet
Cleaning Only
Dual Role User
*
No-EE Only
Yes-EE Onsite
Yes-FC Onsite
Level of service
*
Normal
Urgent
Delivery method
*
Digital (AdobeSign)
US Mail
Number of packets to mail
*
Address to mail the packet to
*
Street Address
Apartment or Unit Number
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Projected start date
*
-
Month
-
Day
Year
Date
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Orion ISO Individualized Home Supports (IHS) Enrollment Packet Request
For questions, please contact HR at 612-400-6412 or isohr@orionassoc.net
Participant
This is the person that receives services. Other terms include, Consumer, Client, or Person Served
Select the number of Participants
*
1
2
3
Participant 1 Legal Name
*
Legal First Name
Legal Last Name
Participant 2 Legal Name
*
Legal First Name
Legal Last Name
Participant 3 Legal Name
*
Legal First Name
Legal Last Name
Employee (1st Signer)
This is the person that is responsible for providing services to the Participant
Employee Legal Name
*
Legal First Name
Legal Last Name
Employee Email
*
example@example.com
Employer
This is the person who holds the IRS Employer Identification Number (EIN)
Employer Legal Name
Responsible Party (2nd Signer)
Also referred to as the Managing Employer. This is the person that is responsible for supervising the Employee. In some cases, the Managing Employer can be the Participant or their Authorized Representative.
Responsible Party Legal Name
*
Legal First Name
Legal Last Name
Responsible Party Email
*
example@example.com
Responsible Party Phone Number
*
Please enter a valid phone number.
Orion ISO Coordinator
This is the person at Orion ISO that provides financial and technical support for the individuals and families they serve and works with each participant to provide financial management services
Orion ISO Coordinator Legal Name
*
Legal First Name
Legal Last Name
Orion ISO Coordinator Email
*
example@example.com
Orion ISO Coordinator Phone Number
*
Please enter a valid phone number.
I-9 Verification
Email of the person verifying Section 2 of the I-9
*
example@example.com
Please verify that you are human
*
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