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.

• Authorization for Release of Personal Information (PDF)
  Use this form to give Optum Bank permission to share your personal and account information with another individual.
• Contribution/Deposit Form (PDF)
  Use this form to contribute to your HSA by mailing in a check.
• Designation of Beneficiary (PDF)
  Use this form to designate beneficiaries of your HSA.
• Name Change Notification Form (PDF)
  Use this form to make corrections to your name or notify us that your name has changed.
• Transfer of Funds - ACH Deposit (PDF)
  Use this form to contribute to your HSA by transferring funds from another bank account via ACH.
• Transfer of Funds - ACH Withdrawal (PDF)
  Use this form to request a withdrawal via ACH.
• Withdrawal/Distribution Form (PDF)
  Use this form to request a withdrawal from your HSA.
• IRA Rollover/Transfer Request Form (PDF)
  Use this form to rollover or transfer funds from an IRA.
• Customer Request Account Closure Form (PDF)
  Use this form if you decide to close your HSA with Optum Bank.
• Additional Debit Card Request Form (PDF)
  Use this form to request an Optum Bank Health Savings Account Debit MasterCard^® for your spouse or a dependent.
• Transaction Dispute Form (PDF)
  Use this form to dispute an ACH withdrawal or unauthorized activity on your Debit MasterCard.
• Excess Contribution and Deposit Correction Request Form (PDF)
  Use this form to request an excess contribution refund or a correction to a contribution.
• Withdrawal Correction Form (PDF)
  Use this form to redeposit funds withdrawn in error from your account.
• HSA Rollover/Transfer Request Form (PDF)
  Use this form to authorize the transfer of HSA funds from another custodian to Optum Bank.