HSA Power of Attorney Disability / Incapacity Form_2021.1
Health Savings Account Power of Attorney
Disability / Incapacity Form
If you have any questions about HSAs or completing this form, please contact Customer Service at (603) 647-1147 Ext. 1.
1. Complete all sections of this form.
2. Signatures must be notarized.
3. Email, mail, or fax completed form to:
Address: 111 Charles Street, Manchester, NH 03101
Part I Consumer Information
*Consumer Name (First, MI, Last) *Employer Name (If sponsored by an employer plan)
*Birth Date (MM/DD/YYYY) *
Part II Power of Attorney Designation
* Attorney-in-fact Name (First, MI, Last)
*Birth Date (MM/DD/YYYY) *
*City *State *Zip
HRC Total Solutions and WEX Inc. is hereby authorized to recognize the signature subscribed below in the payment of funds or
transactions of any business for this account. All transactions shall be governed by applicable laws and the Health Savings
Account Custodian Agreement. To the extent allowed by law, this authorization shall survive my disability or incapacity, and shall
remain in effect until HRC Total Solutions receives written notice of revocation and a reasonable opportunity to act on such notice.
By signing below, I authorize the attorney-in-fact identified above to perform any act I may perform pursuant to my HSA Custodial
Agreement with HRC Total Solutions. This Power of Attorney is effective upon my disability or incapacity. I shall be considered
disabled or incapacitated for purposes of this Power of Attorney if a physician certifies in writing that, based on the physician’s
medical examination of me, I am mentally incapable of managing my financial affairs. I authorize the physician who examines me
for this purpose to disclose my physical or mental condition to another person for purposes of this Power of Attorney. This
authorization includes, for example, the ability to: (1) endorse, cash, or deposit checks or other items payable to my order, (2)
withdraw funds from this account via any means allowed for this account, including but not limited to checks, ACH and wire
transfers; and (3) give instructions for the handling of any and all matters in connection with this account. I understand the powers I
give to my attorney-in-fact, and any limitations on those powers are between the attorney-in-fact and me, even if HRC Total
Solutions and WEX Inc. have express written notice of those powers. I agree to hold HRC Total Solutions and WEX Inc., harmless
and be responsible for any damages or costs incurred due to my HSA Administrator’s reliance on this Power of Attorney.
*Signature of HSA Account Holder *Date
*Signature of Attorney-in-fact *Date