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HSA Forms

HSA Account Application—this form contains the documents necessary to establish a Heath Savings Account at Heritage Bank. Print and complete the application form, and return it to Heritage Bank to open your HSA.

HSA Designation or Change of Beneficiary form—use this form to select or change the current beneficiary designation of your HSA.

HSA Contribution Instructions Form—use this form to document an HSA contribution transaction.

HSA Distribution form—This form is designed to assist an HSA owner in selecting an HSA distribution reason and method.

HSA Rollover Review—this form is designed to assist you in meeting your responsibility to only roll over eligible assets.

Request for Transfer to an HSA form—this form is designed to assist you in the non-reportable movement of assets from one HSA to another HSA or from an Archer Medical Savings Account (MSA) to an HSA.