Educational Assistance Repayment

IMPORTANT: This Education Assistance Repayment form is for Intermountain employees who did not meet the work commitment requirement after receiving educational assistance and need to pay money back to Intermountain Healthcare. After completing this form, payment to Intermountain will be withdrawn from the employee's bank account on file. This form is not for tuition reimbursement for current Intermountain employees. Employees seeking tuition reimbursement should create a tuition reimbursement request in Workday and contact Ask HR with any additional questions.

* Designates required information

Identification

ID Type *

Employee ID *

Facility *

Personal Information

First Name *

First Name cannot be blank.

Last Name *

Last Name cannot be blank.

Address *

Street Address required.

Address 2

City *

City is required.

State *

State is required.

Zip *

Please fill in your Zip Code.

Email *

Please enter your email.

Phone *

Please enter your phone number.

Education Assistance

Payment Amount *

Payment Amount required. Payment Amount must be greater than zero.

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