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Saint Paul Public Schools, District 625
360 Colborne Street
Saint Paul


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Health Savings Account (HSA) Forms

Health Savings Account Forms

2023 HSA Savings Account Form

2024 HSA Savings Account Form

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.