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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 2016 New Hire Orientation Benefit Summary for Lewiston Campus
  2016 New Hire Benefits Enrollment

Choice Time & Extended Sick Bank Accruals (Salaried)
  2016 Insurance Rates for Medical, Dental and Vision Choice Time & Extended Sick Bank Accruals (Hourly)
  Partner Agreement CMMC Parking Map & Violation Notice
  Payroll Direct Deposit

Voluntary Benefits:

  2016 Pay Check Dates PPACA Notice, August 2012
  2016 Holiday Schedule  
  Qualifying Event Form  
  W4 Federal and State 2016  
  Change of Name/Address Change

 

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

About Creditable Prescription Drug Coverage and Medicare:

    2014 Medical and Dental Summary Annual Report
    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
    SBC-1.1.14-Medical-Plan-$500-deductible
   

SBC-1.1.14-Medical-Plan-$1500-deductible

  Forms Documents
Dental Plan   Dental Summary Plan Description
    Dental SPD Amendment
  Forms Documents
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  
  Forms Documents
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
  Forms Documents

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


Notice of Withdrawal


Special Tax Notice January 2015

    Frequently Asked Questions (FAQs)
    Summary Plan Description, Restated April 1, 2011
    Summary of Material Modification - July 2015
    2014 Annual Funding Notice
  Forms Documents
Retirement: 403(b) & 401(k) Plan Address Change Online Access Instructions
  Beneficiary 403(b)Fund Performance Notice 10.14
  Deduction Change 403(b) Fee Disclosure 10.14
  Enrollment Form 403(b) Fund Change Disclosure 10.14
  403(b) Auto Enrollment notice 457(b) Fee Disclosure 10.14
  401(k) Auto Enrollment notice 2015 Enrollment Form
 

403(b) Hardship Distribution Form

401(k) Hardship Distribution Form

2015 Insurance Rates
  Withdrawal/Transfer Request Form
2014-401k-EACA-Notice-of-Auto-Enroll
  403(b) and 401(k) Loan Application with Instructions 2014-401k-Investment-Profile-11.14
  Waiver 2014-403b-EACA-Notice-of-Auto-Enroll-11.14
  EACA 403(b) notice 12.1.15 2014-403b-Investment-Profile-11.14
 
EACA 401(k) notice 12.1.15
2014 403(b) Summary Annual Report
    2014 401(k) Summary Annual Report
  Forms Documents
Retirement: 457 Plan Beneficiary Designation  
  Distribution Request  
  Distribution/Rollover Request  
  Hardship Distribution Request  
 

Healthy Decisions

  Forms Documents
  How to Complete Your Health Risk Assessment  
  Fitness Center/Home Workout Tracking Form  
  Reimbursement Request Form  
  Weight Watchers or Like Weight Loss Program  
  Healthy Decisions Wellness Spouse/Partner Record  
  Personal Health Manager: Getting Started  
  Biometric Screening Documentation Form  
  Pregnancy Biometric Screening Exemption Form  
 

 

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