Health Savings Account Document Archives | BRI

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Withdrawal Request Form (UMB)
- Request a withdrawal from your UMB Health Savings Account
Name Change Form (UMB)
- Form to change the name associated with your Health Savings Account.
Transfer Form (UMB)
- Form for transferring your account to UMB from another trustee
Beneficiary Form (UMB)
- Designate the beneficiary for your Health Savings Account.
Over-The-Counter (OTC) Chart
- Sample chart of OTC items that may be eligible from your HSA.
Medical Necessity Directive Form 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 for your records.)
Enrollment/Change Form HSA
- To enroll or make changes in your HSA program.
Direct Deposit Form
- This form allows an employer, or other organization, to establish direct deposit into your HSA.
Change of Contact Information (UMB)
- This form can be used to update your name, email address, telephone number, and home address information for your HSA to UMB Financial Corporation.