Health Saving Accounts Forms

Please download and mail the appropriate forms to:

Health Savings Administrators
10800 Midlothian Turnpike
Suite 240
Richmond, VA 23235

Phone: (804) 378-7756
Phone: (888) 354-0697
E-Mail: info@hsaadministrators.com

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Open Your Account

Online Enrollment Form

Setting up a Health Savings Account has never been easier!

Enrollment Form

An alternative to our Online Application Form, HSA offers a downloadable form. Complete the form and mail to the address below.

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Make a Contribution to your HSA

Existing Customer Contribution Form

ACH Debit Authorization Agreement

We can automatically make deposits to your HSA from your checking account.

Transfer Form

Use this form if you want your current HSA or MSA custodian to transfer your account to Health Savings Administrators but you have not received a check from your custodian

Rollover Form

Use this form if your current MSA or HSA has sent you a check that you want to deposit with Health Savings Administrators.

IRA to HSA Transfer Form

Make a one-time transfer from your IRA.

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Request a Reimbursement

Request for Reimbursement Form

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Manage your Account

Change of Address

Investment Change Form

Change of Beneficiary

Request an Additional Debit Card

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Legal Documents

HSA Custodial Agreement

Additional Provisions for Health Savings Accounts

Mutual Fund Account Disclosure Form

Debit Card Account Disclosure Form

Debit Card Authorization Form for Health Savings Accounts

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Miscellaneous

Online Access Instructions

Online Services Agreement

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