HEALTH SERVICES PAYMENT PAYROLL DEDUCTION AGREEMENT
DATE:
NAME:
EMPLOYEE ID#:
CONTACT#:
LOCATION/PROGRAM NAME:
AltaPointe Health employees, and their dependents, enrolled in the AltaPointe Health insurance plan are eligible to receive services at Accordia Health and Wellness for a discounted fee. Payment is required at time of service.
However, employees and their dependents may opt to have their payment deducted from the employee’s paycheck per the agreement below. Additionally, if payment is not received at the time of service and/or if payment is not received within 30 days of a statement being generated, the payment will automatically be deducted from the employee’s paycheck.
The deductions will occur as follows:
Balances less than $100 will be deducted from one paycheck.
Balances greater than or equal to $100 will be deducted from three paychecks.
Please note the employee and their dependents will be responsible for payment of services furnished or provided by outside providers or companies. Payments to outside providers or companies are not eligible for payroll deduction.
Amount to be deducted: $
My signature below signifies I understand that I am responsible for all charges related to the services provided to me by Accordia Health and Wellness.
I hereby authorize AltaPointe Health to deduct the copayments for services for myself and my dependents in accordance with the above terms. I understand and I agree that I am responsible for satisfying the amounts. I understand and agree that any amount that is due and owing at the time of my separation, whether voluntary or not, will be deducted from my last paycheck or any other amounts that may be owed to me. This authorizes AltaPointe Health to retain the entire amount of my last paycheck in compliance with the law. I further understand and agree that deductions will be made after any mandatory taxes as well as for any employer programs in which I have enrolled, for which I am eligible, or to which I have agreed.
Employee Signature:
Date: