Associate Payroll Deduction Form

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Associate Payroll Deduction Form

NOTE: Associates will need to fill out this form every time they want to start / change / remove payroll deductions.

You will be asked to sign below each time you request a change.

If you have multiple account numbers please list each in boxes 1 - 7 below if you want included in this payment plan. Separate forms are submitted for Hospital versus Professional visits.

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Associate Payroll Deduction Form

Associate Information

Which Lima Memorial facility is your account with? *

Lima Memorial Health System
Lima Memorial Physicians

Associate Account Number *

Associate Name *

Badge Number *

Last Four Digits of S.S. # *

Associate is:

Full-Time
Part-Time

Active Current Payment Plan?

Yes (please complete the below)
No

New / Add-on Payment Plan?

New (please complete the below)
Add-on (please complete the below)

No. 1 - Account Number

1 - Account Number

1 - Balance

No. 2 - Account Number

2 - Account Number

2 - Balance

No. 3 - Account Number

3 - Account Number

3 - Balance

No. 4 - Account Number

4 - Account Number

4 - Balance

No. 5 - Account Number

5 - Account Number

5 - Balance

No. 6 - Account Number

6 - Account Number

6 - Balance

No. 7 - Account Number

7 - Account Number

7 - Balance

Deduct this amount per pay from payroll check $

Deduct the above amount from payroll check until the ENTIRE SUM is paid in full $

If associate should leave the organization before the entire balance is paid, any balance remaining will be withdrawn from the last paycheck.

Consent date:

Captcha

Associate Links

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