Get Hsa Deduction Authorization Change Form - Denvergov

Filling out the HSA Deduction Authorization Change Form is an essential process for managing your health savings account deductions effectively. This guide will provide clear and detailed instructions to help you complete the form confidently and accurately.

Follow the steps to fill out your HSA Deduction Authorization Change Form easily.

1. Use the ‘Get Form’ button to access the HSA Deduction Authorization Change Form. This action will open the form in the designated editor for you to fill out.
2. Begin by entering your name in the designated field at the top of the form. Make sure to include your full name as it appears on your identification.
3. Next, input the date you are completing the form. This is important for processing and tracking your request.
4. Fill in your location information accurately, as it may be used for verification purposes.
5. Provide your Social Security Number (SSN) in the specified field. This is necessary for identification and processing by the city's payroll system.
6. Enter your Employee ID. This helps in linking your form to your employment record.
7. State your current HSA deduction amount in the designated blank, ensuring it reflects your existing payroll deductions.
8. Select your enrolled medical plan from the options provided: Denver Health HDHP, Kaiser HDHP, or UnitedHealthCare HDHP. Mark your choice clearly.
9. In the section for making changes, specify the new annual contribution you wish to make. Write the amount in the corresponding blank space.
10. Alternatively, if applicable, you may choose to override your current per paycheck deduction. Fill in the new amount and the date until which this deduction should remain effective.
11. Complete the form by signing it in the Employee Signature area. Your signature indicates your authorization for the changes.
12. Once you have filled out the form, save any changes made, then you can download, print, or share the document as needed. Finally, return the completed form to the Office of Human Resources Benefits via the provided contact methods.

Complete your HSA Deduction Authorization Change Form online today!