Expense Forms

Expense
     – Sample Expense
Family Reimbursed Respite
      – Sample FRR
Mileage Reimbursement (Page 1)  – Required
Mileage Reimbursement (Page 2)  – If needed/supplemental
       – Sample Mileage      (Page 1& 2)
Multiple Vehicle Mileage   – only if requested by ISS or QA

Employment Forms

Conditional Hire
Disciplinary Form
DOL IA12_3
DSP Staff Evaluation
Employee Status Change
Internal Job Interest
New Hire
NYS IT 2104
Personnel Change Form
Unemployment IA12_3
W4
W9

Benefits/Insurance Forms

Complete Insurance Packet
Declination of Insurance
Dental
Medical – BCBS Enrollment/Change
Medical – EPO
Vision

Pension Forms

Salary Deferral Election Form
Summary Plan Description

In case of an Accident

Claimant Information Packet
Compensation and Pharmacy Benefits
Notification Concerning Worker’s

Housing Subsidies

ISS Housing Subsidy Information
ISS Housing QA Checklist
ISS Housing Participant Agreement
ISS Housing Plan of Justification (Letter of Justification)
ISS Housing Payment Authorization Form

Broker and Self Direction Coordination

Direct Provider Purchased Service Agreement
LIC Agreement Annual Review
LIC Agreement FI Ind
LIC Agreement Ind
OOSR
OOSR Request Additional Form
Paid Neighbor Agreement
Paid Neighbor New Payment Process Form
Self-Direction Summary Notes Sample
Self-Direction Termination
Support Broker Agreement
Web Approver Designee

Quality and Corporate Compliance

Corporate Compliance Training 2021
Incident Reporting Training 2021
Positive Safeguard Planning Tool
QA Flyer for New Staff