Health Savings Account Forms

Required

• Health Savings Account Application
• Complete this form to open your account. You can choose from three administrative fee and interest-rate options, which give you greater flexibility to manage your account. More Information about HSA options. If your HSA has been set-up by your employer, an option has been selected for you. If you are unsure as to the plan you have, contact SelectAccount Customer Service to find out which option your employer has selected.

  Note: this form can also be completed online.

• Health Savings Account Contribution Form
• Use this form each time you send in a contribution check or to set up an automatic contribution from your bank. Note: this form can also be completed online.

Optional

• Medical Crossover Form
• Have your medical claims automatically submitted from your health plan to SelectAccount and avoid paperwork. Note: this form can also be completed online.
• Dental Crossover Form
• Have your dental claims automatically submitted from your dental plan to SelectAccount and avoid paperwork. Note: this form can also be completed online.
• Direct Deposit Form
• Authorize electronic transfer of your reimbursements from your reimbursement account to your checking or savings account. Note: this form can also be completed online.
• Individual Health Savings Account Debit Card Request Form
• Use this form to request a debit card for your Health Savings Account. If your HSA has been set-up by your employer, you may or may not have an option to add a debit card. Please contact your employer for more information.

As Needed

• Health Savings Account Withdrawal Request Form
• Request a withdrawal from your account. Note: this form can also be completed online.
• Letter of Medical Necessity
• In order to determine eligibility for Potentially Eligible Expenses, you will need to obtain a Letter of Medical Necessity from your healthcare provider.
• One Time IRA to HSA Rollover Request Form
• Transfer money from an IRA to your SelectAccount HSA. Note: This IRA to HSA rollover cannot exceed the HSA contribution limit for the year.
• Health Savings Account Transfer Request Form
• Transfer money from a previous health savings account or medical savings account custodian to your SelectAccount HSA.
• Health Savings Account Rollover Form
• Complete this form, if you're contributing money to your SelectAccount HSA that you've received from a previous health savings account or medical savings account.
• Member Requested Authorization for Release of Information (ARI)
• Complete this form if you want SelectAccount to release information about you to someone else (for example: an agent or family member).
• Appeal Form
• Use this to provide additional information to have a denied claim reviewed.