Forms

Health Saving Account Forms

The following includes the health saving account forms provided by Health Savings Administrators:

Open Your Account

• Online Enrollment Form

Setting up a Health Savings Account has never been easier! Simply fill out the Online Enrollment Form and begin saving today.

• Enrollment Form

(An alternative to our Online Application Form, HSA offers a downloadable form. Complete the form and mail to the address below.)

Make a Contribution to Your HSA

• Existing Customer Contribution Form
• ACH Debit Authorization Agreement

We can automatically make deposits to your HSA from your checking account. You choose to have the money transferred on either the 1st or 20th of the month. We do the rest.

• Transfer Form

(Use this form if you want your current HSA or MSA custodian to transfer your account to Health Savings Administrators but you have not received a check from your custodian.)

• Rollover Form

(Use this form if your current MSA or HSA has sent you a check that you want to deposit with Health Savings Administrators.)

• IRA to HSA Transfer Form

Request a Reimbursement

• Request for Reimbursement Form
• Electronic (ACH) Reimbursement Authorization

We can automatically deposit the reimbursements to your HSA to your personal checking account. Complete and fax or mail this form.

Manage Your Account

• Online Access Instructions
• Change of Address
• Investment Change Form
• Change of Beneficiary
• Request an Additional Debit Card

Legal Documents

• HSA Custodial Agreement
• Additional Provisions for Health Savings Accounts
• Debit Card Account Disclosure Form

Tax-Related

• IRS Form 8889
• IRS Form 8889 Instructions