Health Saving Accounts Forms

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Open Your Account
Make a Contribution to Your HSA
Request a Reimbursement
Manage Your Account
Legal Documents
Tax-Related

Open Your Account

Online Enrollment Form
Setting up a Health Savings Account has never been easier! Simply fill out the Online Enrollment Form and begin saving today.

Enrollment Form
(An alternative to our Online Application Form, HSA offers a downloadable form. Complete the form and mail to the address below.)

Make a Contribution to Your HSA

Existing Customer Contribution Form

ACH Debit Authorization Agreement
We can automatically make deposits to your HSA from your checking account. You choose to have the money transferred on either the 1st or 20th of the month. We do the rest.

Transfer Form
(Use this form if you want your current HSA or MSA custodian to transfer your account to Health Savings Administrators but you have not received a check from your custodian.)

Rollover Form
(Use this form if your current MSA or HSA has sent you a check that you want to deposit with Health Savings Administrators.)

IRA to HSA Transfer Form

Request a Reimbursement

Request for Reimbursement Form

Electronic (ACH) Reimbursement Authorization
We can automatically deposit the reimbursements to your HSA to your personal checking account. Complete and fax or mail this form.