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Important Disclosures, Forms, Interest Rates and Fees

The below forms are available to help you open, access, and manage your HSA. All forms can be downloaded, printed and either mailed or faxed to our Customer Assistance Center. If you are enrolled in Internet Banking, some of these forms and related activities can be completed online.

Please note: You will need Adobe Reader to view our forms. If you do not have Adobe Reader installed on your computer, please click here for a free download of the program.


Account Set-up Forms


Sign up for an HSA
Click on the above link to begin enrollment.

Account Information Change Form
Change your name, designation of beneficiary or authorized signer.

Authorized Signer
Log in to Internet Banking to add an Authorized Signer to your account, or complete this form.

Authorized Signer Revoked
Remove an authorized signer from an account.

Designation of Beneficiaries
Designate, change or remove a beneficiary.

Change Address
Log in to your Internet Banking account and click "Profile" to change your address.

Disclosures, Rates and Fees


E-Sign Agreement
Download information on electronic recordkeeping of disclosures, documents and statements.

Account Disclosures
Download disclosures associated with your HSA.

Interest Rates and Service Fees
Download the rates and fees associated with your HSA.

Online Banking Agreement
Download the agreement terms associated with using Internet Banking.

Privacy and Opt Out Notice
Download statements regarding your right to privacy.

Contribution and Withdrawal Forms


Contribution Form
Log in to Internet Banking to set up a transfer, or submit this form.

MSA to HSA Rollover Form

HSA Transfer/Rollover Form

IRA to HSA Transfer Form

Order Checks and Debit Cards
Log into Internet Banking to order checks and debit cards.

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

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

Withdrawal Form
Withdraw HSA funds.