This form is used to do a trustee-to-trustee transfer from an existing HSA to your new BRI HSA (powered by Piermont Bank/First Dollar).
This form allows an employer, or other organization, to establish direct deposit into your BRI HSA (powered by Piermont Bank/First Dollar).
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.)
To enroll or make changes in your HSA program.