HSA TRANSFER REQUEST INSTRUCTIONS
The Health Savings Transfer Request form is used to request the transfer of HSA funds at another financial institution
to The HSA Authority-Old National Bank. These instructions will assist you in completing the HSA Transfer Request form. If
you do not have an open Health Savings Account with The HSA Authority, please open your account through our online
application process first. Approximately one week after you apply, you will receive a Welcome Letter in the mail that will
include your new account number.
Complete the attached form and send it to USI Benefits Department and we will take care of moving the funds for you.
A representative from The HSA Authority will sign the form and then forward it to your
current institution. When the funds
are received, we will mail you a receipt for the deposit.
Please note: It is important that the transfer is processed in this manner to ensure that it is coded as a transfer
and not a new contribution. Your current institution may charge a fee to transfer and/or close the account.
To fill out the HSA Transfer Request Form:
Part 1 Recipient:
Complete with your information and your HSA Authority Health Savings Account number.
(The account number will be on your Welcome Letter or account statement.)
Part 2 Accepting HSA Trustee or Custodian:
This section is pre-filled.
Part 3 Current Account Owner:
Complete with your information and the HSA number for the account you are transferring from.
Part 4 Current Account Trustee or Custodian:
Complete with current trustee or custodian bank’s information.
Part 5 Transfer Instructions:
To move all the funds to your HSA Authority Account:
Under Transfer Options select One-Time Transfer and check Entire Account Balance. If you wish to close
the account, check This Transfer Will Close the Current Account.
Under the Make Payable To section list Old National Bank as Custodian and list your name as Recipient.
The Asset Handling section can be left blank.
Part 6 Signatures:
Please sign on the first line at the bottom. The form does not need to be notarized unless your current
institution requires it. The last line is for a representative from The HSA Authority to sign before forwarding
it to the other institution.
If you have questions, please call our Client Care Center at 888.472.8697 for assistance. They are available Monday
through Friday, 8:00 am – 8:00 pm ET and Saturday 8:00 am – 1:00 PM ET. Additional information is available on our website