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Forms for DMAS Employees

Forms for DMAS employees are listed by category below. DMAS managers and HR administrators can search internal or management forms on For assistance accessing or completing these forms, please contact DMAS Human Resources.

Health Insurance Portability and Accountability Act (HIPPA) and Secure Email Information acknowledgement form.

File Download:  2 HIPAA and Secure E-mail Acknowledgement Form--03222019

An health care provider who transmits any health information electronically in connection with standard financial or administrative transactions must comply with HIPPA. DMAS as a health plan is a covered entity.

File Download:  3 HIPAA Awareness and Encrypt Email slides--03222019

(Updated 3-22-2019)

File Download:  3A HIPAA HINTS and Encryption Poster (03222019)

(Last updated 04-16-18)

File Download:  4A COV DMAS Security--CHANGE Access ReqForm- 041618

As a user of the Department of Medical Assistance Services (DMAS) information systems, you understand and agree to abide by the DMAS Information Systems Security Access Policy and Standards for Workforce Members (Employees, Wage and/or Contractors) and the terms which govern your access to, and use of, the information and computer services of DMAS.

File Download:  4B COV DMAS Security--ADD-Transfer Access ReqForm--041618

As a user (operator) of the Department of Medical Assistance Services (DMAS) information systems, you should agree to abide by all applicable Commonwealth of Virginia and DMAS agency policies, procedures, and standards which relate to the security of DMAS information systems and the data and the terms which govern your access to and use of the information and computer services of DMAS.

File Download:  5 VAMMIS Request Form - (Word 97-2003)-052914

Access will be granted to you by DMAS as a necessary privilege in order to perform authorized job functions. You are prohibited from using or knowingly permitting use of any assigned or entrusted access control mechanisms (such as login IDs, passwords, terminal IDs, user IDs, file protection keys or production read/write keys) for any purpose other than those required to perform your authorized employment functions.

File Download:  6 ECM User Request-FORM for Xerox SAS-Citrix-Remedy-ESS Server--052814

You have been given a copy of the Department of Medical Assistance Services Policy No: 10, “Use of the Internet and Electronic Communication Systems.” You understand that it is your responsibility to read and abide by this policy, even if you do not agree with it.

File Download:  8 Acknowledge Receipt of Internet Policy

You understand and agree that as a member of the work-force at the DMAS, you have a legal duty to hold in complete confidence any medical, employee, and other confidential work-related information that you see or hear, or come into contact with, in the performance of your duties for DMAS.

File Download:  9 DMAS Confidentiality-NDA-Agreement-SSA-HIPAA ACK (Word 97-2003) 041618


File Download:  10 Parking DMAS 1 Application (ONLY FOR FT EE)


File Download:  11 Parking DMAS 2 (Pre-Tax) (ONLY FOR FT EE)

Designate beneficiary for VRS Basic and Optional Group life insurance and for your defined benefit retirement contribution account by completing this form.

File Download:  12 Beneficiary Form (VRS2) 01-14

Information provided in this form is collected by DMAS to comply with the requirements of the Immigration Reform and Control Act of 1986. This law requires that employers verify the identity and employment authorization of individuals they hire for employment to preclude the unlawful hiring, or recruiting or referring for a fee, of aliens who are not authorized to work in the United States.

File Download:  14 I-9 Form (07-17-2017)

These instructions will assist you in properly completing Form I-9. The employer must ensure that all pages of the instructions and Lists of Acceptable Documents are available, either in print or electronically, to all employees completing this form.

File Download:  14A I-9 Instructions (07-17-2017)

CommonWealth of Virginia Department of Taxation Worksheet.

File Download:  15 VA- 4 08-11

Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.

File Download:  16 Federal Tax Witholding W-4 2019

Employees must complete this form to enlist contacts in case of emergency.

File Download:  17 Emergency Contact Information Form 121015

The Commonwealth of Virginia's Policy 1.05 on Alcohol and Other Drugs states that the following acts by employees are prohibited....

File Download:  18 DHRM - Summary of Alcohol and Drug Policy (03-04)

The purpose of this policy is to ensure the appropriate, responsible, and safe use of
electronic communications and social media by employees. This policy establishes
minimum standards for all state employees. Agencies may supplement this policy as
necessary, as long as such supplement is consistent with this policy

File Download:  19 DHRM Policy 1.75 Use of Electronic Communications and Social Media (031711)

(Updated 1-1-2019)

File Download:  20A DHRM Civility in the Workplace - Policy Guide 2019

The Code of Business Ethics and Conduct (Code) communicates what is expected
of all workforce members and contracted staff working at the Department of Medical Assistance Services (DMAS). It is a set of principles designed to alert employees and other workforce members about the conduct expected of them in the workplace. The Code provides guidance pertaining specifically to the quality of service, compliance with laws and regulations, policies and procedures, avoiding conflicts of interest, health and safety, human resources, interpersonal interactions, the protection and use of information, state property, and assets.

File Download:  21 Code of Business Ethics and Conduct

A Virginia state law which took effect July 1, 1993 is intended to assist the Division of Child Support Enforcement in collecting child support payments from absent parents.

File Download:  22 Child Support Declaration

State employees are prohibited from ordering from state contracts or individual state agency/institution contracts directly or by using agency orders with subsequent reimbursement to the agency.  This in accordance with the Agency Procurement and Surplus Property Manual (APSPM), Section 2.1(a) Mandatory Sources, Term Contracts

File Download:  23 Using State Contracts for Personal Use

Please sign this document to indicate you have seen and read this handbook.

File Download:  24 Receipt of Employee Handbook

Your signature below indicates your receipt of this policy summary of Policy 1.05, Alcohol and Other Drugs

File Download:  25 Signature Pages for Policies and Documents - Classified, Wage

Your signature below indicates your receipt of this policy summary of Policy 1.05, Alcohol and Other Drugs

File Download:  26 Signature Pages for Policies and Documents - Temps


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DMAS Policies

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