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, January 2024
Evaluation Form, March 2023
Hiring Form, January
 2024
In-Activation, January 2024
NYS IT 2104, January 2023
Personnel Change Form – Contact information changes: name, address, phone number, and/or email address January 2024
Unemployment IA12_3
W4, January 2023
W9

Benefits/Insurance Forms

Dental
Employee Election Form,  January 2024
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, January, 2024
Direct Provider Purchased ADM, Nov. 2022
Direct Provider Purchased Compliance Policy, Nov. 2022
Direct Provider Purchased Utilization Report Template, Feb. 2023
Direct Provider Purchased Utilization Report Template Sample, Feb. 2023
LIC Agreement Annual Review
LIC Agreement FI Ind
LIC Agreement Ind
OOSR Request (fillable), PDF, Jan 2023
Paid Neighbor Agreement
Paid Neighbor New Payment Process Form
Planning Team Minutes Template, PDF, Apr. 2023
Self-Direction Summary Notes Sample
Self-Direction Termination
Support Broker Agreement
Web Approver Designee, PDF, 06/23

Quality and Corporate Compliance

IDGS Service Request Form, PDF, Jan. 2023
Corporate Compliance Training 2022
Incident Reporting Training 2022
Positive Safeguard Planning Tool
QA Flyer for New Staff