Employee Authorization for Payroll Deduction
Health Savings Account (HSA)
This form is for employees who want to have money withheld from their paychecks by California Lutheran
University and deposited into their health savings account (HSA) on a pre-tax basis.
Employee Name Employe ID #
I elect to withhold:
$__________________ from my (bi-weekly/monthly) payroll and apply these funds to my PayFlex HSA.
IRS Code Section 223
2018 HSA Employee Contribution Limits:
$3,450 – self only
$6,900 – family
*Catch up contribution $1,000 annually – 55 and older
2019 HSA Employee Contribution Limits:
$3,500 – self only
$7,000 – family
*Catch up contribution $1,000 annually – 55 and older
Please note: Special rules apply to the HSA contributions for partial-year enrollment: If you enroll in the HSA for an
effective date other than January 1st, you are limited to the amount you can contribute to the H S A for the calendar year.
Please refer to the HSA Design Guide for further details or contact PayFlex directly at 888-678-8242.
You may access your HSA directly with PayFlex at: http://www.payflex.com/
844-729-3539
Return completed forms to:
Human Resources
Attn: Angie Guerrero
Fax: 805-493-3655
Email: aguerrero@callutheran.edu
Employee Signature Date
I elect to:
Begin my deduction
Change my deduction
Stop my deduction
Effective date: _______________
For HR Office Use:
Enrolled in FSA verified Enrolled in HSA compatible medical plan P/S updated HR Received: _________
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signature
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