Prisma Health C.A.R.E. 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 * Please select your primary campus or market * Baptist Easley HospitalMidlandsOconee Memorial HospitalTuomey HospitalUpstate/Corporate If you are on the Prisma Health Network, find your Employee ID Number Here. If you are not on the network, your Employee ID Number can be found on Workday under your “Job Details” page. 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.
