Important Message
Important Message

Health Savings Accounts Forms


HSA Beneficiary Designation Form

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



HSA Contribution Form

Make a normal, mistaken distribution, or rollover contribution to your HSA.



HSA Death Distribution Request Form

Use to authorize a distribution of assets from a decedent’s HSA.



HSA Distribution Request Form

Request a distribution from your HSA.



HSA Individual Transfer Form

Use to initiate a direct transfer of funds from your current HSA.



HSA Legal Name Change Form

Use to make a legal name change on your HSA.



HSA Plus Custodial Agreement

HSA Plus Online Portal Terms and Conditions

Patriot Act Notice

eSign Notice

Taxpayer Identification Number Certification

HSA Plus Disclosures and Agreements

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