Health Savings Account Forms
Use this form to start, stop, increase or decrease your annual election for deductions with your Health Savings Account.
This form is a fillable PDF.
1 - Download the form to your computer
2 - Fill it out on your computer, save
3 - Email completed form to firstname.lastname@example.org
Health Savings Accounts can be started, increased or decreased or stopped through out the plan year. Changes are effective the beginning of the following month from the date it is received in the Benefits Office.
This form is not used during Open Enrollment. Online enrollment required annually.