Human Resources

Human Resources forms and links

403(b) forms & links
CSEA Vision Care Forms
Employee forms (teacher timesheet, mileage, expense, direct deposit, leave req.)
Health Insurance Forms and Links
Federal/State Tax forms
Life Insurance Form
PGP Flex Spending Plan forms & link
Policies & Information (Medicaid, HIPAA, Workers Comp.)

403(b) forms & links

Smart Choice 403(b) www.cpcfs.com
Smart Choice Enrollment Booklet
Smart Choice Universal Availability Notice 2019
OMNI www.omni403b.com
403 (b) Retirement Plan Document
403 (b) Salary Reduction Agreement
OMNI 403(b) Why me?
403 (b) Contribution Percentage Change Form
OMNI - 2020 Universal Availability Notice

Tax Forms

IT-2104 - NY State Tax - Employee’s Withholding Allowance Certificate
W-4 - Federal Tax - Employee’s Withholding Allowance Certificate
I-9 - Employment Eligibility Verification

Employee forms

WinCapWEB Employee Self Service
WinCapWEB Leave Request Instructions
Home Teaching Timesheet
CSEA Timesheet
Teacher & Hourly Timesheet
Mileage Reimbursement Form
Employee Expense Claim Form
Direct Deposit (Adobe pdf fill-in form)
Notice of Employee Leave
Conference Request Form
STA Course Approval Form
Sick Bank Enrollment Form

PGP Flexible Spending Plan forms & link

PGP website www.thepreferredgroup.com
PGP Flexible Spending Plan Description
PGP Flexible Spending Plan Summary
PGP Eligible and Ineligible Expenses
PGP Blank Flex Plan Enrollment Form
PGP OTC Form
PGP Letter of Medical Necessity Form
"Benny" Card Request Form for Saranac CSD Employees
PGP Reimbursement Voucher
PGP Flex Direct Deposit Form

Health Insurance Forms & Links

CEWW Health Insurance

Empire Blue Cross website www.empireblue.com

Empire Blue Cross Customer Service Representative (email This email address is being protected from spambots. You need JavaScript enabled to view it. or call (518)419-3161 Monday Thru Friday 8:30 a.m. to 5:00 p.m.)

Empire Blue Cross Enrollment Form

Empire Blue Cross Claim Form

Ingenio Mail Order (Call 1-833-203-1739 or Fax 1-800-378-0323)

Ingenio Claim Form

Empire Blue Cross Platinum Plan 1 and 2 Benefit Descriptions

Empire Blue Cross Bronze Plan Benefit Descriptions

LiveHealth Online (telemedicine) - This benefit is covered at 100% for Plan 2 members and a cost of $11.80 for Plan 1 members. When you log in, the system references the cost of $59, however, once you elect a provider and go through the process, your actual cost will show.

LiveHealth Member Registration / LHO._Covid-19.pdf

CHIP Notice

Dept. of Labor ACA Compliance Notices

Drug Evaluation Request Form

CEWW Plan 1 Classic Traditional Comparison to Classic Blue

CEWW Plan 2 Classic Traditional Comparison to Classic Blue

Life Insurance Form

Life Enrollment Form-Saranac CSD

Policies

Medicaid Compliance Policy
Medicaid Compliance Program
Appendix A - Confidential Disclosure Policy
Appendix B - NYS Medicaid Compliance Policy
New Employee Informational Packet
Claimant Work Related Information Packet
HIPAA Notice

CSEA and NYSUT Vision Care Forms

CSEA Vision Employee Benefits Enrollment Form
CSEA Vision Care Benefits Description