Take Care of Business
Forms for Health Savings Accounts (HSA)
These forms are provided for use with a Health Savings Account.
Change of Contact Information
This form can be used to update your name, email address, telephone number, and home address information for your HSA.
Contribution / Refund Deposit Slip
This form is used when depositing a refund check to your HSA or mailing in an HSA contribution.
This form allows an employer, or other organization, to establish direct deposit into your HSA.
To facilitate a new HSA payroll deduction or change an existing HSA payroll deduction after the HSA is open and established. If an account is not open, please use the HSA Enrollment Form.
To enroll in your HSA program.
Medical Necessity Directive Form
To use for personal documentation of medical services/items, such as over-the-counter medicines and drugs, that require additional documentation from a licensed health care provider. (Retain for your records.)
|Over-The-Counter (OTC) Chart |
Sample chart of OTC items that may be eligible from your HSA.
This form must be completed and signed immediately following account opening. It can also be completed to add an account signer (such as a spouse) to the HSA and designate an account beneficiary.
Click here for additional miscellaneous HSA forms.