Ballad Health - Payroll Deduction

1
Email
example@example.com
2
Full Name* This field is required.Legal Name, or as on your hospital documentation.
First Name
Last Name
3
Employee ID* This field is required.
4
Email* This field is required.This does not work (well) with Internet Explorer. If you are having trouble, please try Microsoft Edge, Firefox, or Chrome.
example@example.com
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5
Phone Number* This field is required.
6
Shipping Address* This field is required.
Street Address Line 1
Street Address Line 2
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7
Which Ballad Hospital do you work at?* This field is required.
Administration - All Hospitals
Bristol Regional Medical Center
Dickenson Community Hospital
Franklin Woods Community Hospital
Hancock County Hospital
Hawkins County Memorial Hospital
Holston Valley Medical Center
Indian Path Community Hospital
Johnson City Medical Center
Johnson County Community Hospital
Johnston Memorial Hospital
Greeneville Community Hospital East
Hospice
Lonesome Pine Hospital
Madison Health and Rehab
Mountain View Regional Hospital
Niswonger Children’s Hospital
Norton Community Hospital
Russell County Hospital
Smyth County Community Hospital
Sycamore Shoals Hospital
Unicoi County Hospital
8
Payroll Deduction Authorization* This field is required.I authorize deductions from my payroll check. If my employment terminates for any reason from Ballad Health, I authorize any remaining balance to be deducted from my final payroll check. I further understand and agree that if my final payroll check is not sufficient to satisfy any remaining balance due for this purchase, I will remit payment of any remaining balance (after deduction of the final payroll check) within five (5) days of my last date of employment at Ballad Health. If terms of this agreement are not met the balance could be turned over to a third party for collection in which I am responsible for all collection/legal fees.
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