Thank you for allowing us to serve you.
Where to return your form?
Optum Bank, P.O. Box 271629, Salt Lake City, UT 84127
By Fax: 1-800-765-6766
© 2016 Optum Bank. All Rights Reserved. HSAs are individual accounts administered
30663-052016 Rev. 05/16 or offered by Optum Bank, Member FDIC.
Use this form to give permission to share your personal and account information with another individual. Customer
service professionals can be reached by calling the number on the back of your debit card (Monday - Friday from 8
a.m. to 8 p.m. Eastern time) if you have any questions while completing this form.
059 CO HSA
Account Holder Name:
Group Id #: State of Residency:
Individual Who Is Authorized To Receive Account Information
Name of Authorized Individual:
Authorized Individual’s Street Address:
I authorize Optum Bank’s customer service professionals to provide information regarding my account, including
but not limited to balance and transaction history, to the individual named above.
I understand and agree that:
• The individual named above will not be authorized to perform any account maintenance.
• This authorization pertains to information obtained from customer service only.
• I am the sole individual authorized to access and maintain my account online.