Health Savings Account Forms

  • 2021 Health Savings Account (HSA) Form

    Use this form ouside of your hire event, or Active Enrollment 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


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  • 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.