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Online Forms
Please note: All forms are in PDF format. You will need Adobe Reader to view these forms. If you do not have Adobe Reader installed on your computer, you can download it for free by clicking here.
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HSA Application
This is the form to fill out to enroll in our HSA. If you want to enroll online, please click here.
Account Information Change Form
You can use this form to update your account if you've experienced multiple changes, such as: name change, address change, changed beneficiaries, or want to add/change your Authorized Signer.
Authorized Signer
This form allows you to designate an Authorized Signer for your HSA.
Designation of Beneficiaries
If you wish to designate beneficiaries to your HSA, please complete this form.
Change Address
To update your address or establish a seasonal address, please see the profile section in our Internet Banking system.
Reorder Materials
When you need more checks, deposit tickets, or a new debit card, use this form to order them.
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Automatic Contribution Form
Allows you to make contributions directly from your personal checking or savings account.
Contribution Form
Use this form to make a contribution to your account. You can also use our Internet Banking system to make an online contribution. Click here for instructions for making online contributions.
Employer Contribution Form
For employers to use when making contributions for employees (including individual, employee pre-tax, and employer contributions).
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Excess Removal Form
Complete this form when you have gone over your contribution limit and need to remove the excess funds.
Distribution Reversal Form
If you use HSA funds for non-qualified medical expenses, you can complete this form and return the funds.
Withdrawal Form
Use this form to make a contribution or withdraw funds from your account.
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Authorized Signer Revoke Form
Used to remove the Authorized Signer from your account.
Eligible Medical Expenses
Contains a list of qualified medical expenses.
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MSA to HSA Rollover Form
Complete this form if you currently have an MSA and want to transfer those funds to your HSA.
HSA Transfer/Rollover Form
Complete this form if you want to transfer your HSA from another custodian to HSA Bank.
IRA to HSA Transfer Form
Allows you to make a one time transfer from your IRA to HSA. IRA transfers are limited to the HSA annual contribution maximum.
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Telephone Banking Instructions
Instructions for using our automated telephone service (Bankline) to access your health savings account.
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Employer Sign-up
For employers that would like to access HSA Bank's Employer Administration Area to manage its employee list, download resources, and make contributions online.
Employer Guide
Comprehensive guide for employers, detailing enrollment, contributions, and disbursement options.
Group Online Contribution Form
For employers that would like to make contributions to employee HSA's online. The ACH Origination Agreement (included in the Group Online Contribution Form PDF) must be submitted with the Group Online Contribution Form.
ACH Instructions
How to use an Automated Clearing House to contribute funds to employee accounts.
Employer Contribution Form
For employers to use when making contributions for employees (including individual, employee pre-tax, and employer contributions).
Employee Add/Remove Form
For employers to add or remove an employee.
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E-sign Agreement
Provides information about the use of electronic records.
Account Disclosures
Disclosures associated with your Health Savings Account.
Account Disclosures(2006)
Interest Rates and Service Fees
Please see our rates and fees under Product Services.
Online Banking Agreement
These are the terms associated with using Internet Banking.
Privacy Statement
A statement from HSA Bank and Webster Bank regarding your right to privacy.
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IRS Form 1099-SA
IRS form needed for your HSA Distributions. Instructions included.
IRS Form 5498-SA
IRS form needed for your HSA Contributions.
Instructions for Form 1099-SA and 5498-SA
Instructions for form 5498-SA
IRS Form 8853
IRS form needed for your MSA.
Instructions for IRS Form 8853
Instructions for IRS Form 8853
IRS Form 8889
Used to report HSA contributions, distributions, and your tax deduction.
Instructions for IRS Form 8889
Instructions for IRS Form 8889
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