Prisma Health CARE Fund Payroll Deduction Form Prisma Health Care Fund Payroll Deduction Authorization Form Personal Information Title Mr.Ms.Mrs.MissDr.Other Title Name * Name First First Last Last Address * Address Street Address Street Address Street Address 2 Street Address 2 City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Email Address * Phone Number * Work Information Employee ID Number * Department Name * Donation Information Donation amount per period $ Use slider below to choose number of pay periods for deductions (26 = Full year) 1 Donation amount per pay period $ Total number of pay periods Yearly donation total $ Signature Enter your full name to sign this form * Date * CAPTCHA Submit If you are human, leave this field blank.
