Forms & publications

Employee Authorization for Payroll Deduction to Health Savings Account (HSA) (PEBB) 2022

Use this form to have your employer withhold money from your paychecks and deposit it into your health savings account (HSA) on a pretax basis. Check with your payroll department before submitting this form; not all employers can arrange for payroll deductions. You must be enrolled in a consumer-directed health plan (CDHP) with an HSA before you can start a payroll deduction.

Employee Authorization for Payroll Deduction to Health Savings Account (HSA) (PEBB) 2023

Use this form to have your employer withhold money from your paychecks and deposit it into your health savings account (HSA) on a pretax basis. Check with your payroll department before submitting this form; not all employers can arrange for payroll deductions. You must be enrolled in a consumer-directed health plan (CDHP) with an HSA before you can start a payroll deduction.