HSA forms

Download and follow the instructions printed on a variety of account forms to complete common account maintenance tasks.

Sign in to your account to access forms:

• Excess contribution refund
• Contribution corrections
• Redeposit funds withdrawn in error from your account
• Rollover funds from an IRA
• Name change
• Designate a beneficiary.
  • For SSN/TIN beneficiaries, sign in.
  • For Estate and Trust beneficiaries, use fax form by clicking here.
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  Health savings accounts (HSAs) and Medicare Advantage Medical Savings Accounts (MSAs) are individual accounts offered or administered through Optum Bank ® , Member FDIC, a subsidiary of Optum Financial, Inc. Optum Financial, Inc. is not a bank or an FDIC insured institution. HSAs are subject to eligibility requirements and restrictions on deposits and withdrawals to avoid IRS penalties. State taxes may apply. Fees may reduce earnings on account.

  Flexible spending accounts (FSAs), dependent care assistance programs (DCAPs), health reimbursement arrangements (HRAs), Commuter and Parking Benefits, Tuition Assistance Plans, Adoption Assistance Plans, Surrogacy Assistance Plans, Wellness Benefits, and Lifestyle Accounts (collectively, “Employer-Sponsored Plans”) are administered on behalf of your plan sponsor by Optum Financial, Inc. ("Optum Financial") and are subject to eligibility and restrictions. Employer-Sponsored Plans are not individually owned and amounts available under the Employer-Sponsored Plan are not FDIC insured.

  This communication is not intended as legal or tax advice. Federal and state laws and regulations are subject to change. Please contact a legal or tax professional for advice on eligibility, tax treatment and restrictions. Please contact your plan administrator with questions about enrollment or plan restrictions.

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