The below forms are available to help you open, access, and manage your HSA. Forms can be emailed, mailed or faxed to our Client Assistance Center. Some of these activities can be completed in your online account.

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 enroll by form, or enroll online.


Authorized Signer Revoked
Remove an authorized signer from an account.


Designation of Beneficiaries
Designate, change or remove a beneficiary.


Change of Address
Use the form or log in to your account and click "Profile" to change your address.


Contribution and Distribution Forms

Contribution Form
Log in to your account to set up a transfer, or submit this form.


HSA Direct Transfer Request Form


HSA Rollover Request Form


IRA to HSA Transfer Form


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


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


Distribution Form
HSA funds distribution.


Transfer Out Instructions
Steps for transferring to a new custodian.


Disclosures, Rates and Fees

Account Disclosures
Download disclosures associated with your HSA.


Health Savings Account Fee and Interest Rate Schedule
Schedule may vary based on employer relationship.