Members / Important Forms

Important Forms


The below forms are available to help you open, access, and manage your HSA. Forms can be emailed, mailed or faxed to our Client Assistance Center. Some of these activities can be completed in your online account.

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Account Set-up Forms

Sign Up for an HSA
Click on the above link to enroll by form, or enroll online.

Authorized Signer Revoked
Remove an authorized signer from an account.

Designation of Beneficiaries
Designate, change or remove a beneficiary.

Change of Address
Use the form or log in to your account and click "Profile" to change your address.

Disclosures, Rates and Fees

Account Disclosures
Download disclosures associated with your HSA.

Standard HSA Interest Rates and Fee Schedule
Schedule may vary based on employer relationship.

Contribution and Withdrawal Forms

Contribution Form
Log in to your account to set up a transfer, or submit this form.

HSA Direct Transfer Request Form

HSA Rollover Request Form

IRA to HSA Transfer Form

Excess Removal Form
Remove funds that exceed your annual contribution limit.

Distribution Reversal Form
Return funds used for non-eligible expenses or overpayments.

Withdrawal Form
Withdraw HSA funds.

Transfer Out Instructions
Steps for transferring to a new custodian.