Health Savings Account (HSA) Change Form
You may enroll in a HSA or change your HSA contribution as often as once per month. All changes will be effective until the end of the current Benefits plan year, June 30, 2024. You must be enrolled in a DPS Consumer Driven Health Plan (CDHP) to have an HSA. 

Your total calendar year contribution cannot exceed the IRS annual maximums (IMPORTANT NOTE: DPS’s contribution of $27.92 per paycheck is included in the annual maximum):
- Employee Only coverage: $4,150
- Employee + Dependent(s) (spouse, children, or family) coverage: $8,300
* If you are age 55 or over, an additional $1,000 can be added to the maximums 
* IRS Limits are effective January 1, 2024

Your change request made below will be your per paycheck contribution. Employees receive two paychecks per month, on the 7th and 22nd.
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Your First and Last Name *
Your 9 digit DPS ID number *
This is a request to... *
I would like to change my PER PAYCHECK contribution to... *
The employee's contribution will be in addition to the DPS contribution of $27.92 per paycheck. Employees are paid two times per month, on the 7th and 22nd.
Please enter the email you prefer your confirmation message be sent. *
You can designate your personal or DPSk12 email to be your preferred communication option.
Acceptance and Authorization
By completing and submitting this form I understand that I am requesting and authorizing Denver Public Schools to reduce my salary by the specified amount and to apply the amount of the salary reduction as a contribution into my Health Savings Account.

I understand that my total calendar year cannot exceed the maximum set by the IRS and that I am responsible for any penalties incurred if I exceed this limit.

I further understand that it is my responsibility to check my paystubs through Employee Self Service to verify that my requested changes are made properly after the effective date of the change (monthly thereafter) and report any discrepancies to the Benefits Department at Employee_Benefits@dpsk12.org immediately upon discovery.

I understand the DPS ID number I entered above must match what is assigned to me in the system for my request to be processed. If my DPS ID number is not correct, my request will not be processed.

If you understand and agree with the above statements, please click "Submit" below.
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