Forms & publications

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.

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 high deductible health plan with an HSA before you can start a payroll deduction.

Ardon Health Protected health information (PHI) disclosure authorization form. Ardon Health is a member of Washington State Rx Services (WSRxS).

This form directs the Uniform Medical Plan's (UMP) administrator, Regence, to communicate with you about your personal health information (PHI).

This form directs Washington State Rx Services (WSRxS) to communicate with you about your personal health information at the address you select. This form does not apply to your health care provider. You must give your provider separate, specific instruction about what health information they may share and with whom.