Account Forms

You can complete many transactions for your HSA online. For those you can't, use the following forms and follow instructions printed on them.


orange_arrowName Change Notification form (PDF)
Use this form to make corrections to your name or notify us that your name has changed.

orange_arrowInformation Authorization form (PDF)
Use this form to give Optum Bank permission to share your personal and account information with another individual.

orange_arrowDesignation of Beneficiary form (PDF)
Use this form to specify who should receive the funds in your HSA when you die.

orange_arrowIRA Rollover/Transfer Request form (PDF)
Use this form to rollover or transfer funds from an IRA.

orange_arrowCustomer Request Account Closure form (PDF)
Use this form if you decide to close your HSA with Optum Bank.

orange_arrowContribution/Deposit form (PDF)
Use this form when you send in contributions, including contributions from your friends and family, with a check.

orange_arrowTransfer of Funds – ACH Deposit form (PDF)
Use this form to transfer funds to your HSA from a bank account at another financial institution.

orange_arrowAdditional Debit Card Request form (PDF)
Use this form to request an Optum Bank Health Savings Account Debit MasterCard® for your spouse or a dependent.

orange_arrowDebit Card Dispute form (PDF)
Use this form to report unauthorized activity on your Debit MasterCard or charges you believe to be incorrect.

orange_arrowACH Dispute form (PDF)
Use this form to dispute an ACH withdrawal from your account.

orange_arrowWithdrawal/Distribution form (PDF)
Use this form to request a distribution from your account to reimburse yourself or pay a provider for a qualified expense.

orange_arrowExcess Contribution and Deposit Correction Request Form (PDF)
Use this form to request an excess contribution refund or a correction to a contribution.

orange_arrowWithdrawal Correction form (PDF)
Use this form to redeposit funds withdrawn in error from your account.

orange_arrowTransfer of Funds – ACH Withdrawal form (PDF)
Use this form to request a distribution from your account for qualified medical expenses you paid for out-of-pocket.

orange_arrowStatement and Other Documents Delivery Change Request form (PDF)
Use this form to request that your statements and/or other documents be delivered by mail.

orange_arrowHSA Rollover/Transfer Request form (PDF)
Use this form to authorize the transfer of HSA funds from another custodian to Optum Bank.

orange_arrowEmployer Contribution form (XLS)
Submit this form with a check to make contributions to employees' HSAs
Health savings accounts (HSAs) are individual accounts offered by Optum BankSM, Member FDIC, and are subject to eligibility and restrictions, including but not limited to restrictions on distributions for qualified medical expenses set forth in section 213(d) of the Internal Revenue Code. State taxes may apply. This communication is not intended as legal or tax advice. Please contact a competent legal or tax professional for personal advice on eligibility, tax treatment, and restrictions. Federal and state laws and regulations are subject to change.