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