*The total combined amount of both employer and employee contributions cannot exceed IRS maximum contribution limits.
IRS regulations are indexed annually for inflation. If you want to contribute the total annual amount for a tax year in which you were
only HSA eligible for a portion of that year, you must remain HSA eligible through the end of the next tax year or face tax penalties.
©ConnectYourCare Form 400001 00082016
Health Savings Account Enrollment Form
Follow these easy steps:
1. Complete all entries on this Enrollment Form. Please print.
2. Sign and date this form.
3. Submit it to your Human Resources Department
Personal Information
Employee Name
(last name, first name)
Social Security Number
Street Address
(cannot be PO Box)
City, State, Zip Code
Mailing Address
(if different
)
City, State, Zip Code
Day Time Phone Number Email Address
Date of Birth (MM/DD/YYYY)
Enrollment Status New enrollment
Re-enrollment
Marital Status Single Married Divorced Widowed
Health Savings Account Qualification
Your Health Savings Account is your financial asset even if you change employers or health plans. To open a Health Savings Account you
must meet three criteria:
1) You must be covered by a qualified high deductible plan.
2) You cannot be covered by another health plan, including Medicare or Flexible Spending Account. (You may be covered by a Limited
Use Flexible Spending Account or Limited Use Health Reimbursement Arrangement.)
3) You cannot be claimed as a dependent on another individual's tax return.
Health Savings Account (HSA)
Select HSA Decline HSA
I. Annual Employee Contribution
(Not to Exceed Contribution Maximums*)
II. Number of regular pay periods
III. Contribution per pay period (I divided by II)
Authorization and Certification
I accept the terms of the ConnectYourCare HSA enrollment form. I understand that:
• I am authorizing my employer to reduce my compensation by the amount specified. I understand the HSA election I have made will
remain in place from year-to-year until I notify my employer of a change to my HSA election.
• I must report any administrative errors to my payroll administrator or HR department within 10 days of my first payroll deduction of
the plan year.
I will receive a ConnectYourCare Payment Card to access funds in my account. I certify that:
• The card will only be used for eligible medical expenses.
• Claims I pay with the card have not been reimbursed and I will not seek reimbursement from any other plan covering health or
dependent care benefits.
Employee Signature Date
For Employer Use
Date of Hire (MM/DD/YYYY)
Benefits Effective Date
(MM/DD/YYYY)
Annual Employer
Contribution
