Physicians Deduction Form

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Employee #

How Do You Wish To Be Listed?

Donation Amount - I hereby authorize Human Resources to deduct the following amount per pay period from each paycheck. This authorization will continue unless otherwise specified in writing.

$38.46 ($1000 Annually)
$76.92 ($2,000 annually)
$20.00 (Residents Only)
Other

If Other Please Specify Amount

Employee Status

Your gift to one of the following programs or facilities will touch people and help provide for their health needs

Electronic Signature

Clear Signature

Date

Physicians Deduction Form

Assisting North Mississippi Health Services in its vision to provide the nation's best patient- and family-centered care.