Fillable Health Savings Account Enrollment Form

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Health Savings Account Enrollment Form

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The Health Savings Account Enrollment Form form is 3 pages long and contains:

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  • 36 other fields

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HSA_Enrollment_Form_2020.1 Page 1 of 3
Health Savings Account Enrollment Form
If you have any questions about HSAs or completing this form, please contact Customer Service at (603) 647-1147 ext.1.
Part I - Accountholder Profile Information
*Consumer Name (First, MI, Last) *Employer Name (If sponsored by an employer plan)
*Birth Date (MM/DD/YYYY) *
Social Security Number
*Home Phone *Mobile Phone
*Physical Street Address (U.S. address required to open an HSA)
*City *State *Zip
Alternate Mailing Street Address or PO Box
City State Zip
*Email Address *Date of Birth
*Gender Male Female Unspecified *Marital Status Married Single
*Mother’s Maiden Name
*Hire Date *Hours Worked per Week *Payroll Frequency
Part II - Authorization and Eligibility Certification
When opening an HSA with HRC Total Solutions, I understand and agree to the following:
• I am at least 18 years old and cannot be claimed as a dependent on someone else’s tax return.
• I am covered under a high deductible health plan (HDHP).
• I am not enrolled in Medicare.
• I do not have any other non-qualified health coverage.
• I do not have a flexible spending account (FSA) to pay for medical expenses incurred before my medical
plan deductible is met, unless it is limited to pay for dental and vision expenses only.
• My spouse, if applicable, does not have a flexible spending account (FSA) to pay for medical expenses
before their medical plan deductible is met, unless it is limited to pay for dental and vision expenses only.
As a follow-up to this application, you will need to login to the HSA website to accept your terms and conditions.
*Signature *Print Name *Date
HSA_Enrollment_Form_2020.1 Page 2 of 3
Part III - Election for Payroll Deduction
(Complete this section if you are enrolling through your employer’s benefit offering)
I authorize my employer to deduct my HSA contributions from my payroll, and forward them to my HSA.
My health plan coverage Type: Single Family
Note – The HSA has a maximum annual contribution limit that is determined by your health insurance coverage (self-
only/family). Your employer may choose to contribute to your HSA, which will count towards to your maximum
contribution allowed. Your health plan eligibility determines the effective date of your HSA. If you are covered on
December 1, you’re considered eligible for the entire year and not required to pro-rate your contributions. If you cease
to be an eligible individual during the next calendar year, any contributions over the prorated amount may be an
excess contribution. You are solely responsible for determining whether contributions to your HSA exceed the
maximum annual contribution limitation. You are also responsible for notifying the custodian of any excess
contribution and requesting a withdrawal of the excess contribution together with any net income attributable to the
excess contribution. For additional information regarding eligible and contribution limits please go to: www.irs.gov.
2020 Annual Contribution Limit
2021 Annual Contribution Limit
Health Plan
Coverage Level
*Annual Contribution
Limit
Per Month
Health Plan
Coverage Level
*Annual Contribution
Limit
Per Month
Self-Only $3,550 $295.83
Self-Only $3,600 $300
Family $7,100 $591.67
Family $7,200 $600
*Age 55+ eligible for an additional catch-up contribution of $1,000
Your Personal Contribution Election
Annual Maximum
Contribution (plus catch
-
up if eligible)
$ ______________
Minus
( - )
Total Employer
Annual Contribution
$ _____________
Equals
(=)
Your Eligible
Annual
Contribution
$
___________
Divide
( / )
Number of
Payrolls per
Year
________
Equals
=
Your Maximum
Per Pay Period
Payroll
Deduction
$ ________
__
Please withhold $ _______________ from my payroll and apply to my HRC Total Solutions HSA.
Part IV - Debit Card
A debit card will automatically be issued to you to use to make medically qualified purchases from your HSA account.
If you do not wish to have a debit card, then please select below.
I do NOT wish to have a debit card with my HSA
HSA_Enrollment_Form_2020.1 Page 3 of 3
Part V - Bank Account and Reimbursement Method
When I am not using my debit card and request a distribution through the HSA website, then I select the method below to
automatically to receive my HSA distributions.
Paper Check – I wish to have a paper check mailed to me. I understand there may be a per check fee of $2.00.
OR
FREE Direct Deposit – I wish to have distributions automatically deposited into my personal bank account and
will complete the Direct Deposit Setup below. This personal bank account can also be utilized to make a post-tax
contribution to your HSA from the HSA website and the HSA mobile application.
Enter your personal bank account information if Direct Deposit selected above.
*Bank Name
*Address *City *State *Zip
*Account Type
Checking Savings
*Routing # *Account #
Next Steps:
1. Email, mail or fax completed form to:
Email: https://hrcts.com/securemail
Address: 111 Charles Street, Manchester, NH 03101
Fax: 1-866-978-7868
2. Log into the HSA Portal and accept the terms and conditions of my HSA.
3. Verification of my identity is required for opening an HSA and may result in
needing to supply additional information. If this applies to me, then I will be
notified by HRC Total Solutions on how to proceed.
Routing # Account #
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Health Savings Account Enrollment Form

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Completed 16 April 2021

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