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

Disciplinary Form
DOL IA12_3
Direct Deposit Authorization, March 2022
DSP Staff Evaluation
Employee Status Change
Exit Form
NYS IT 2104
People Services Hiring Form
Personnel Change Form
Unemployment IA12_3
W4
W9

Benefits/Insurance Forms

Declination of Insurance
Dental
Employee Election Form
Medical – BCBS Enrollment/Change
Medical – EPO
Vision
VSP

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

Tips for Brokers on Completing Budgets Thoroughly
Housing Subsidy QA Checklist   OPWDD PDF, Nov 5, 2021
Housing Subsidy Participant Agreement    OPWDD PDF, Nov 8, 2021
ISS Housing Subsidy Plan Justification 10/08/20
ISS Housing Subsidy Payment Method Authorization Form

Broker and Self Direction Coordination

Contract to Direct Bill, PDF, June, 2022
Direct Provider Purchased Service Agreement
LIC Agreement Annual Review
LIC Agreement FI Ind
LIC Agreement Ind
OOSR Request
OOSR Request (fillable)
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

IDGS Service Request Form, PDF, Sept. 2022
Corporate Compliance Training 2022
Incident Reporting Training 2022
Positive Safeguard Planning Tool
QA Flyer for New Staff