Employee Sign In About Your Benefits Wellness Programs Events Forms and Documents Help Contact Info
Healthy Decisions Human Resources

Forms & Documents

The forms and documents on this page are generally Adobe® Acrobat® files. To view or print these forms, you need to have the Adobe Acrobat Reader installed on your computer.

Follow the directions on the form and submit to the appropriate party and address.

Benefit Plan/Program Forms Documents
General 2014 New Hire Info and Orientation  
  2014 New Hire Benefits Enrollment

  2014 Insurance Rates for Medical, Dental and Vision  
  Partner Agreement Benefit Summary for Lewiston Campus
  Payroll Direct Deposit Choice Time & Extended Sick Bank Accruals (Salaried)
  2014 Pay Check Dates Choice Time & Extended Sick Bank Accruals (Hourly)
  2014 Holiday Schedule CMMC Parking Map & Violation Notice
  Qualifying Event Form

Voluntary Benefits:

  W4- -Federal and State - 2014 PPACA Notice, August 2012
  Change of Name/Address Change


  Check Request Form  
  Ability Assist (EAP)  
Medical Plan   Medical Summary Plan Description

About Creditable Prescription Drug Coverage and Medicare:

    Summary Annual Report Medical and Dental 10.14
Summary Benefits & Coverage $500
    Summary Benefits & Coverage $1,500
    Understanding Health Care Reform
    Health Insurance HIPPA Privacy Notice
    Summary Annual Report 2012


Dental Plan   Dental Summary Plan Description
    Dental SPD Amendment
Spending Accounts Health Care Benny Card Receipt Claim Spending Account Summary Plan Description
  Health Care Claim FSA Expense List
  Dependent Care Claim  
  Direct Deposit Authorization  
  Doctor's Statement of Medical Necessity  
Life and Disability Insurance Beneficiary Change Form Life/LTD Summary Plan Description (non-MD)
  Ability Assist (EAP) Life Insurance Summary Plan Description (MD)
  STD Premium Rate Sheet LTD Summary Plan Description (MD)
    STD Summary Plan Description

Retirement: Defined Benefit Pension Plan (Frozen 04/01/2011)

Notice of Withdrawal Summary of Material Modifications
    Dear Fellow Letter of February 10, 2011 Announcing Change
    Frequently Asked Questions (FAQs)
    Copy of Notice US Mailed to Active Employee Participants in the Defined Benefit Plan
    Summary Plan Description, Restated April 1, 2011
    2012 Annual Funding Notice
    Summary of Material Modifications regarding lump-sum distributions (December 2012)
    2013 Annual Funding Notice
Retirement: 403(b) & 401(k) Plan Address Change Online Access Instructions
    403(b)Fund Performance Notice 10.14
    403(b) Fee Disclosure 10.14
    403(b) Fund Change Disclosure 10.14
    457(b) Fee Disclosure 10.14
  Beneficiary FAQs for Bridgton Employees - 401(k) to 403(b)
  Deduction Change  
    403(b) Summary of Material Modifications
  Enrollment Form SPD 401k 2012
  403(b) Auto Enrollment notice SPD 403b 2012
  401(k) Auto Enrollment notice

403(b) Summary Annual Report for 12/31/12

401(k) Summary Annual Report for 12/31/12

  Hardship Distribution Request Amendment 401k EACA Notice of Auto Enroll
  Withdrawal Request
Amendment 401k EACA Notice
  403(b) and 401(k) Loan Application with Instructions Amendment 401k EACA SMM
  Waiver Amendment 403b EACA Notice of Auto Enroll
    Amendment 403b EACA Notice
    Amendment 403b EACA SMM
    Free Disclosure 404(a)(5) Statement 8/2012
    403b Fee Disclosure 11/13
    401k Fee Disclosure 11/13
Retirement: 457 Plan Beneficiary Designation  
  Distribution Request  
  Distribution/Rollover Request  
  Hardship Distribution Request  


Visit CAPHIS for links to quality health Web sites referred by the Medical Library Association.