Forms

To open a new account or make adjustments to accounts. Choose a form from the list below:

• Application [PDF]
  Use this application to open your HSA with HSA Resources. Note: if you are participating in an employer plan, you can skip Section 2 as that information will be provided by your employer.
• HSA Application for Groups [PDF]
  Use this application to open your HSA with HSA Resources. Note: use this Application only if you are participating in an Employer HSA plan.
• ACH Contract [PDF]
  Complete this contract to initiate debit and credit entries (ACH transfers) with Falcon National Bank.
• Transfers/Rollovers [PDF]
  Use this form to transfer an HSA/MSA/FSA/HRA from another administrator. If you have already closed your HSA with the other administrator and received a check please check "rollover".
• Designation of Beneficiary [PDF]
  Complete this form to identify who you would like to inherit your HSA or to change your beneficiaries. Note: if you designate your spouse, your HSA will transfer tax free and become your spouse's HSA.
• Account Contributions [PDF]
  To make additional contributions to your HSA please complete, sign and submit this form along with your contribution. Note: check your total contribution limit with our Contribution Worksheet [PDF]
• Account Distributions [PDF]
  If you would like to take a distribution to pay for a medical expense and do not want to use your checking account or debit card, you may also submit a completed Distribution form.
• Employer Contribution [Excel]
  For employers contributing to employee HSAs. Use this form (our your own) to provide us with a breakdown of the contribution between individual employees. Use this form to add and remove employees also.
• HSA Authorized Signer Form [PDF]
  Use this form to give an additional person authorization to sign checks and use a debit card.
• Custodial Agreement [PDF]
  Details fees and additional information related to your account.
• Account Disclosures [PDF]
  Information pertaining to your account.
• HSA Online Banking Agreement [PDF]
  Use this form to sign up for free internet banking (do not check bill pay).
• HSA Payroll Deferral Election Form [PDF]
  This form is for employers that allow payroll deferral into an HSA.