Account Forms

Form Name

Description

Account Authorization

This form authorizes dependents to access your account.

Beneficiary Designation

Designate a beneficiary for your Health Savings Account (HSA).

HIPAA Authorization

In accordance with the Health Insurance Portability and Accountability Act of 1996, HealthEquity will not disclose the protected health information of any plan dependent without prior notification that an individual does not object, or if it can be reasonably inferred from the circumstances that the individual does not object to the disclosure. To allow for the disclosure of your protected health information to your plan sponsor please fill out and return the following form.

Change of Personal Information

Use this online form to update/change your personal information on file with HealthEquity.

HSA Closure Request

Use this online form if you wish to close your HealthEquity Health Savings Account (HSA).

HSA Instructions upon Death

This form provides instructions and required information in the event an account holder is deceased.

HSA Instructions upon Divorce

This form provides instructions for splitting funds due to a divorce or legal separation agreement.

Member EFT

Add an external bank account to use for electronic funds transfers for contributions to your account or for reimbursements from your account.

Upload Power of Attorney

Uploading a power of attorney authorizes your named agent to have full access to your account(s).

Rollover Request

This form can be used to rollover funds into your HealthEquity Health Savings Account (HSA).

Transfer Request

This form can be used to transfer monies directly from another custodian into your HealthEquity Health Savings Account (HSA).

HRA/FSA Letter of Medical Necessity

This form assists you and your health care provider in providing the information we need in order to process your Health Reimbursement Arrangement (HRA) or Flexible Spending Account (FSA) claim.

Return of Mistaken HSA Contribution

Use this online form to correct a mistaken individual contribution made to your Health Savings Account (HSA).

Form Name

Description

HSA Contribution

Use this online form to contribute to your personal Health Savings Account (HSA).

Distribution of Excess HSA Contribution

Use this online form to remove contributions in excess of the allowed amount for a given tax year.

Return of Mistaken HSA Contribution

Use this online form to report a mistaken distribution from your HealthEquity Health Savings Account (HSA).

Form Name

Description

Distribution of Excess HSA Contribution

Use this online form to remove contributions in excess of the allowed amount for a given tax year.

Mistaken HSA Distribution

Use this online form to report a mistaken distribution from your HealthEquity Health Savings Account (HSA).

HSA Reimbursement

Submit for reimbursements from your Health Savings Account (HSA). A complete listing of section 213(d) qualified medical expenses can be found at www.irs.gov.

Reimbursement Account Claims Appeal

Complete this form to appeal a Flexible Spending Account (FSA) or Health Reimbursement Arrangement (HRA) claim processed by HealthEquity. Please only utilize this form after you have already submitted all requested documentation.

Dependent Care Reimbursement

Submit for reimbursement from your Dependent Care Reimbursement Arrangement (DCRA) for your dependent care expenses.

LPFSA Reimbursement

Submit for reimbursement from your Limited Purpose Flexible Spending Account (LPFSA) for your vision and dental expenses.

FSA/HRA Reimbursement

Submit for reimbursement from your Flexible Spending Account (FSA) for qualified medical expenses.

Pay Me Back Claim

Reimbursement for your out-of-pocket expenses.

Retiree Reimbursement Arrangement

Submit for reimbursement from your Retiree Health Reimbursement Arrangement for your eligible premium expenses. Note: please review your plan document to ensure that premiums are eligible to be reimbursed from your plan.

Return of Reimbursement Account Overpayment

Use this online form to correct an overpayment made for your reimbursement account.

HRA/FSA Letter of Medical Necessity

This form assists you and your health care provider in providing the information we need to process your Health Reimbursement Arrangement (HRA) or Flexible Spending Account (FSA) claim.

FSA/HRA Additional Documentation Requested

Use this link to upload additional documentation requested for your Health Reimbursement Arrangement (HRA) or Flexible Spending Account (FSA) request.

Orthodontia Reimbursement

Submit for reimbursement from your Health Reimbursement Arrangement (HRA) or Flexible Spending Account (FSA) for your orthodontia expenses. Note: Orthodontia contracts are typically required with the first submission of orthodontia claims.