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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 Beneficiary Designation

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



HSA Transfer Request

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



Limited Durable Power Of Attorney Authorization for HSA

Designate your spouse or a competent third party to withdraw funds from the account.



HSA Contribution and Investment Selection

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 healthsavingsaccounts@associatedbank.com, 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 Authorization

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



HSA Mistaken Distribution Repayment

Make a deposit to return money that was disbursed inappropriately.



HSA Contribution Eligibility form for Rollover

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

These forms require Adobe Acrobat Reader.

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