HSA Forms

Download the forms and print them out. Follow the check list and instructions. Please contact us with any questions you may have.

New HSA Application Form

Rollover Form

IRA to HSA Rollover Form

A one-time tax-free trustee-to-trustee transfer of IRA funds to an HSA is permitted. The amount transferred may not exceed your maximum allowable annual HSA contribution (for example, $2,900 for single coverage and $5,800 for those with family coverage in 2008). Any money transferred from your IRA counts toward your maximum HSA contribution for that tax year. You may not transfer a "Catch-Up" contribution. You must maintain your HSA-qualified health plan coverage for the entire calendar year for which you are making the transfer or your HSA contribution (including IRA rollovers) will be limited further. You may not take the usual tax deduction for HSA contributions for any funds transferred from your IRA and contributed to your HSA. However, once the IRA funds are deposited in the HSA, they may be used tax-free for qualified medical expenses. Had the funds remained in the IRA, the amount withdrawn would be subject to income tax (and a 10% penalty if withdrawn before age 59-1/2)

If you're 55 and older you can fund your account with an extra "catch up" contribution of $900 for 2008. If you are a couple and each wish to fund "catch up" contribution of $900 you each need to open an HSA.

If you have had your HDHP and are now just setting up your HSA, you may not reimburse yourself for any prior qualified health care expenses.