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Form to change the name associated with your Health Savings Account.
Sample chart of OTC items that may be eligible from your HSA.
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
This form allows an employer, or other organization, to establish direct deposit into your HSA.
This form can be used to update your name, email address, telephone number, and home address information for your HSA to UMB Financial Corporation.
Simplifying the complexity of benefits for maximum savings and peace of mind.
245 Kenneth Drive
Rochester NY 14623-4277
EMPLOYEES: (800) 473-9595
EMPLOYERS: (866) 996-5200
The Beniversal and eTRAC Prepaid Mastercards are issued by The Bancorp Bank, N.A., Member FDIC, pursuant to a license by Mastercard International Incorporated and may be used everywhere Mastercard is accepted. Mastercard is a registered trademark, and the circle’s design is a trademark of Mastercard International Incorporated.
HSA Custodial Services are provided by a separate financial institution. See your HSA Account Agreement for specific account terms.
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