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Forms & Resources
Insurance
Employee Assistance Program
- Help Line (Toll-Free) 1-866-327-2400
- Email Deer Oaks
- COVID19 Response
- Life Coaching (PDF)
- Monthly Employee Newsletter (PDF)
- Monthly Supervisor Newsletter (PDF)
- Nutrition Focus: Eating Healthy (PDF)
- Nutrition Focus: Brighten Up Your Plate (PDF)
- Nutrition Focus: 5 Steps to a Healthier Lunchbox (PDF)
- Resuming School During Covid (PDF)
- Seasonal Affective Disorder (PDF)
- Work Life Childcare (PDF)
- Work Life Services (PDF)
American Fidelity
CareFirst Blue Cross / Blue Shield
- Allegany County Medicare Part D Creditable Coverage
- Enrollment Form (PDF)
- CVS/Caremark Reimbursement Form (PDF)
- CVS/Caremark Mail Order Form (PDF)
- Active Employees: Preferred Provider Organization (PDF)
- Benefits Summary (PDF)
- Health Benefit Options (PDF)
- CareFirst Website
- Employee Newsletter - August 2020 (PDF)
- Employee Poster - August 2020 (PDF)
- CareFirst Wellness program available through Sharecare on the CareFirst website
Flexible Spending Program*
- How Flexible Spending Works (PDF)
- Flexible Spending Account Brochure (PDF)
- Dependent Care Flexible Spending Account (PDF)
- OTC Drugs and Medicines Eligible with a Doctor’s Prescription (PDF)
- CBIZ Flexible Spending Plan Election Form (PDF)
- Online Administration
- FSA Claim Form (PDF)
Life Insurance & Supplemental Insurance
Dental Benefits thru Dominion National (effective 2.1.18)
Vision Benefits America https://www.vbaplans.com/vision
- VBA 1160 Allegany County information Coverage (PDF)
- VBA Election Form (PDF)
- VBA Enrollment Change Delete Form (PDF)
- VBA Enrollment, Change, Delete Form (Email Form) (PDF)
- VBA Enrollment, Change, Delete Form (Print and Mail) (PDF)
- Vision Benefits of America Brochure (PDF)
- Vision Benefits of America Coverage Information (PDF)
General Forms
- Retiree Address and Telephone Update Form (PDF)
- Retiree with Medicare Address and Telephone Update Form (PDF)
Deferred Compensation
- Website: Nationwide Retirement Solutions
- Nationwide Retirement Solutions: Payroll Authorization Card (PDF)
- Nationwide Retirement Solutions: Schedule an Appointment
- Website: Valic -AIG Retirement
CareFirst Blue Cross / Blue Shield Benefit Guides
- Allegany County Medicare Part D Creditable Coverage
- Preferred Provider Organization - Retiree Under 65 (PDF)
- Benefit Summary (PDF)
- Health Benefit Options (PDF)
One Exchange Information for Retirees with Medicare
(HRA: Health Reimbursement Act)
State of Maryland Retirement and Pension System
State of Maryland Pre-Retirement Planning Seminar
Contact & Leave Forms
- Personal Information Update Form (PDF)
- Change of Address Form (PDF)
- FMLA: Certification of Health Care Provider (PDF)
- Leave Request Form (PDF)
- Leave of Absence Form (PDF)
Employment Forms
- Application (PDF)
- Background Check Release Form (PDF)
- Disclosure Authorization and Release (PDF)
- Employment Eligibility Verification Form (I9) (PDF)
- Grievance (PDF)
- Incident Report (PDF)
Personnel Action Forms (Supervisors)
Allegany County United Way Campaign Forms
Payroll and Tax Forms
- Authorization for Automatic Deposit (PDF)
- Change of Address Form (PDF)
- W-4 (Federal Income Tax Withholding Form (PDF))
- (MW-507 ) Employees (Maryland Income Tax Withholding Form) (PDF)
- WV Withholding (PDF)
- WV Certificate of Non-Residence (PDF)
- W9 - Request for Taxpayer ID Number & Certification (PDF)