HSA Reimbursement Form
Mail or fax completed forms to:
Address: HealthEquity,An:MemberServices
15 W Scenic Pointe Dr, Ste 100, Draper, UT 84020
Fax: 801.727.1005
www.healthequity.com
866.346.5800
HSA_Reimbursement_Form_20190809
PrimaryAccountHolderInformaon
Last Name First Name M.I.
Street Address City State ZIP
E-Mail Address (required) Dayme Phone
( )
SSN or HealthEquity ID Number
ReimbursementInformaon
Provider Name Date of expense
Paent Name Total Reimbursement
*
Type of expense: c Medical c Prescripon c Dental c Vision (Note: No documentaon is needed. Keep receipts for your records.)
*
If the requested reimbursement amount is higher than your available balance, we will only process the reimbursement up to the available balance
in the account.
Anaccountclosurefeeisheldinreservefromyouraccountandmaynotbeusedforreimbursement.
ReimbursementMethod
c Opon1—Check
This method is slower. Please allow 7–10 business days to receive your check. A$2.00feewillbedeductedfromyourhealth
savingsaccount(HSA).
c Opon2—Usetheveriedelectronicfundstransfer(EFT)accountalreadyedtomyHealthEquity®HSA.(If an EFT is not on
le, a check will be sent and a $2.00 fee may apply. Please allow 7-10 business days for the check to arrive.)
c Opon3—Transferthefundstothefollowingaccount.
(Note: E-mail address is required for EFT.)
Account type: c Checking c Savings
Financial instuon:
City/state:
Roung number:
Account number:
Formmustbeaccompaniedbyacopyofavoidedoractualcheck.
ReimbursementAuthorizaon
By signing below, I authorize HealthEquity to reimburse me from my health savings account (HSA) for my expense in the manner
specied above and I represent that the informaon I provided in this request is true and complete.
Name (please print) Signature Date
Reimbursement requests can also be made online at www.healthequity.com.
