Health Savings Accounts Forms

Health Savings Accounts Forms

Find helpful forms for managing your Associated Bank Health Savings Accounts here. If you don't see the HSA form you need, call us at 800-992-2651.

HSA Designation of Death Beneficiary

Identify who should receive your HSA assets in the event of your death.

HSA Rollover Certification

Move money to Associated Bank from another HSA custodian or trustee within your 60 day rollover window.

HSA Transfer Request

Directly transfer all or part of your HSA to another trustee or custodian.

Limited Durable Power Of Attorney Authorization for HSA

Designate your spouse or a competent third party to withdraw funds from the account. Along with the Limited Power of Attorney Authorization, the HSA Supplemental form should be completed by the LPOA. Be sure to print and return both forms together.

Contribution Investment HSA Form

Make a deposit to return money that was disbursed inappropriately, or to make a contribution other than pre-tax direct deposit.

Qualified Medical Expenses

Examples of qualified medical expenses.

HSA Qualified Expense Reimbursement Form

Send this form to Associated Bank via secure email to, or mail to: Associated Bank, NA Attn: HSA Department MS 7009, PO Box 19097, Green Bay, WI 54307-9097, or fax to 920-405-2324.

HSA Withdrawal Statement

Present this HSA form to the bank to make any withdrawal for reasons involving excess contribution or disability.

These forms require Adobe Acrobat Reader.



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