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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 2026 pebb employee authorization for payroll deduction to health savings account 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 or benefits office before submitting this form
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Not all employers can arrange for payroll deductions. We can help you get access to the care you need when you need it. This form replaces all enrollment/change forms previously submitted
You must complete the entire form, including the dependent section for any children you want to continue to cover.
The public employees benefits board (peb board) has authorized the following changes effective january 1, 2026 The public employees benefits board (pebb) program will provide more information about these and other changes in october before annual open enrollment. Access manuals, forms, enrollment guides, and other resources to support benefits administrators (bas) with the administration of public employees benefits board (pebb) benefits. For 2026 open enrollment information visit the ump pebb open enrollment webpage
Use this form to report the change to your employer. To enroll in pebb benefits, employees should contact their payroll or benefits office All pebb employees can also go online to the pebb program’s website to review the timelines, required forms, and additional documentation needed to ensure they and their dependents are enrolled correctly: Follow the instructions provided by the pebb program
They will forward your enrollment information to unitedhealthcare
You can get 2026 plan information online by going to the website below
