Forms & publications

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PEBB Employee authorization for payroll deduction to health savings account (HSA) 2019

50-098-2019

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.

Form

PEBB employee authorization for payroll deduction to health savings account (HSA) 2020

50-098

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.

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School employee authorization for payroll deduction to health savings account (HSA) 2020

20-0086

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.

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UMP (Ardon Health) Prescription drug protected health information (PHI) disclosure authorization form

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

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UMP (WSRxS) Prescription drug authorization for release of confidential information

This Uniform Medical Plan (UMP) form is to authorize the use or disclosure of personal health information by Washington State Rx Services (WSRxS).

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UMP Applied Behavior Analysis (ABA) services authorization form

This form is for requesting preauthorization of Applied Behavior Analysis (ABA) Therapy services.

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