Prisma Health-Upstate Foundation

A brighter future of care.

Prisma Health Team Member Giving Payroll Deduction Authorization Form

Please complete this form to authorize payroll deductions. Anticipated start of deductions is within the next three pay periods.

For more information, please contact Cyndie Ford, Upstate Foundation, by phone at 864-797-7744 or by email at Cynthia.Ford@prismahealth.org.

Prisma Health Team Member Giving Payroll Deduction Authorization Form

Personal Information

Name
Name
First
Last
Address
Street Address
Street Address 2
City
State/Province
Zip/Postal

Work Information

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.

Gift Designation

Medical Education & Workforce Development
Psychiatry
Bradshaw Institute for Community Child Health & Advocacy
Cancer Institute
Children’s Hospital-Upstate
Heart & Vascular Services
Neuroscience Institute
Nursing
Roger C. Peace Rehabilitation Hospital
Women’s Services
The Canine F.E.T.C.H. Unit
Community Health
Other
$
1

$

$

Signature