Pharmacy Payroll Deduction Authorization

Pharmacy Payroll Deduction
Authorization
Novant Health employees! We offer the convenience of payroll deduction so you don’t have to worry if you
have enough cash for your prescription copay. Submit this payroll deduction authorization and we will have
your pharmacy charges deducted from you next paycheck.
To be eligible for payroll deduction you must be actively working (or on a paid leave of absence).
Note: You are not eligible for payroll deduction of prescription drug copayments if you are: No longer employed by Novant Health, On an unpaid leave
of absence, Continuing your medical coverage through COBRA, A contract employee through a 3rd party.
___________________________ ___________________________ _________________ _____________
Employee First Name
Last Name
DOB
Employee ID #
___________________________ ___________________________ _________________
Dependent First Name
Last Name
DOB
___________________________ ___________________________ _________________
Dependent First Name
Last Name
DOB
___________________________ ___________________________ _________________
Dependent First Name
Last Name
DOB
I authorize payroll deduction at the following Novant Pharmacy locations:
Novant Health Pharmacy Home Delivery
Free 1st Class Mail
Novant Health Specialty Pharmacy Services
255 Charlois Blvd, Winston-Salem, NC
Novant Health Pharmacy - Winston
255 Charlois Blvd, Winston-Salem, NC
across the street from NH Winston-Salem Health Care
Novant Health Pharmacy - Mountainview
212 Moore Road, King, NC
next door to NH Mountainview Medical
Novant Health Pharmacy - Forsyth Med
3333 Silas Creek Parkway, Winston-Salem, NC
in the lobby of NH Forsyth Medical Center
Novant Health Pharmacy - Maplewood
100 Robinhood Medical Plaza, Winston-Salem, NC
in the lobby of NH Maplewood Family Medicine
Novant Health Pharmacy - Salem
105 Vest Mill Circle, Winston-Salem, NC
in the lobby of NH Salem Family Medicine
Novant Health Pharmacy - Presby Med
200 Hawthorne Lane, Charlotte, NC
in the center courtyard of NH Presbyterian Medical Center
Novant Health Pharmacy - Westgate
1381 Westgate Center Dr. Winston-Salem, NC
in the lobby of NH Forsyth Internal Medicine
Novant Health Pharmacy - Kernersville
291 Broad Street, Kernersville, NC
in the lobby of NH Kernersville Family Medicine
Novant Health Pharmacy - Oncology Specialist
1010 Bethesda Court, Winston-Salem, NC
in the lobby at NH Derrick L Davis Cancer Center
Novant Health Pharmacy - Prince William
8700 Sudley Road, Manassas, VA
2nd floor or NH Prince William Medical Center
By signing below you certify that you are actively employed at Novant Health. You authorize deduction from your paycheck the sum of the
copayment(s) incurred from use at a Novant Health Pharmacy. Copayments will not be spread out over several pay periods; the entire amount of
your copayment will be deducted from your next paycheck. If you do not have sufficient funds in your paycheck to cover pharmacy charges, you'll be
required to pay balance by cash, check, or charge (no FSA cards).
Employee Signature: __________________________________________
Send the completed form to [email protected] or fax 336-718-1551.
For questions call 336-718-1044, or toll free 888-718-9044.
Payroll Deduction is not available at all pharmacy locations.