Request for Additional Debit Card Authorized User
Thank you for allowing us to serve you.
Where to return your form?
By Mail: Optum Bank, P.O. Box 30777, Salt Lake City, UT 84130
By Fax: 1-800-765-6766
© 2016 Optum Bank. All Rights Reserved. HSAs are individual accounts administered
30653-052016 Rev. 05/16 or offered by Optum Bank, Member FDIC.
To request an additional Health Savings Account Debit MasterCard
for an authorized user for your account,
please complete and return this form to the address or fax below. Cards will be mailed to the address on file for
your account and will arrive 7 to 10 business days from the date the request is processed.
Please note: This form cannot be used to request replacement cards. If one of your cards has been
damaged, or is lost or stolen, please contact customer service so that we can take the appropriate fraud
prevention measures. 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); cards can be reported lost or stolen 24 hours a
008 CO HSA
Account Holder Information
Account #:
Account Holder Name:
Group Id #: State of Residency:
Authorized User Information
Please Note:
Authorized User names are limited to 26 characters, including spaces.
Name of Authorized User 1:
Name of Authorized User 2:
Name of Authorized User 3:
Account Holder Authorization
I authorize Optum Bank to issue a debit card to my spouse or dependent(s) named above. The card can be used to
make withdrawals from my account. I understand that the individual named above will be an authorized user of my
debit card, and that I will be liable for all charges made by the authorized user
Account Holder Signature