Enrollment

Health Savings Account Application
Complete this form online to open your account. You can choose from three administrative fee and interest rate options, which give you greater flexibility to manage your account.

HSA Beneficiary Designation Form

Direct Deposit Form
Sign in to authorize electronic transfer of your reimbursements from your HSA to your bank account.

Debit Card Request Form
Sign in to request a debit card for your HSA.

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 a family member).

Contributions

Health Savings Account Contribution Form
Sign in to your account and complete the HSA Contribution form online or use this form to send in a contribution check or to set up an automatic contribution from your bank.

One Time IRA to HSA Rollover Request Form
Transfer money from an IRA to your SelectAccount HSA. Note: This rollover cannot exceed the HSA contribution limit for the year.

Transfer Request Form
Transfer money from a previous health savings account or medical savings account custodian to your SelectAccount HSA.

Rollover Form
Complete this form if you are contributing money to your SelectAccount HSA that you've received from a previous health savings account or medical savings account.

Reimbursement Return Form
Use this form to return a payment to your account.

Withdrawals

Withdrawal Request Form
Sign in to request a withdrawal from your account.

Link to Forms on the Blue Cross and Blue Shield of Kansas Website (www.bcbsks.com)

Please note that clicking on this link will direct you away from the SelectAccount website.

Investment & Fee Information

SelectAccount HSA Individual Interest Rates and Pricing Sheet

Basic Investment Account Mutual Fund Options
See a listing of the current mutual fund options available to you.

Reference Guide

HSA Member Guide
Get a detailed description of HSAs and how they work.

Eligible Expense Information

HSA Eligible Medical Expense Listing
Learn the general guidelines about eligible and ineligible expenses

Over-the-Counter Drugs Eligible Expense Listing
Find out which over-the-counter drugs are eligible for reimbursement from your HSA account.

HSA Custodial Agreement

HSA Terms and Conditions
The contractual agreement between the account holder and SelectAccount.

HSA Future-savings Calculator
Estimate the future savings potential and financial benefits of contributing to an HSA.

HSA Maximum-contribution Calculator
Understand annual contribution limits and potential tax-savings from making pre-tax payroll contributions to an HSA.