Individual HSA Enrollment Form

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P.O. Box 30192, Salt Lake City, UT 84130-0192 800-538-5038 selecthealth.org

Health Savings Account (HSA) Enrollment Form

Complete this form if you have chosen a High-Deductible Health Plan (HDHP), with HealthEquity as your Health Savings Account (HSA) administrator. Email your completed form to individualenrollment@selecthealth.org or mail the form to the address listed above attention Enrollment. If you have chosen a HDHP and you don’t complete and send this form, an HSA will not be set up for you. However, failure to complete and send this form will not affect your insurance coverage

Subscriber First Name

Last Name

Subscriber ID

A. HSA ENROLLMENT

This form gives us authorization to open an HSA for you. Your HSA is used to contribute funds to pay for qualified healthcare expenses. Even if you change employers or health plans, your account will remain active until you close it and remove all funds. To open an HSA, you must meet IRS criteria:

You must be covered by a qualified HDHP on the first day of the month.
You must not already have an active HSA or HRA account.
You generally cannot be covered by another health plan, including Medicare.
You cannot be claimed as a dependent on another individual’s tax return.

These criteria are explained in more detail in the HSA Custodial Agreement available at healthequity.com

HSA Effective Date

The chosen effective date must be on or after the effective date of your medical qualified High-Deductible Health Plan (HDHP). If you qualified for an HSA the first day of the last month of the previous year, you may choose December 1 as your effective date

B. COVERED MEMBERS

Add all family members currently enrolled on my medical plan to the HSA.

Exclude all family members listed below from the HSA

First Name

Last Name

Date of Birth

First Name

Last Name

Date of Birth

First Name

Last Name

Date of Birth

First Name

Last Name

Date of Birth

First Name

Last Name

Date of Birth

First Name

Last Name

Date of Birth

First Name

Last Name

Date of Birth

First Name

Last Name

Date of Birth

C. SIGNATURE

I understand the following about HSA enrollment:

By signing this form, I have requested an HSA to be set up in my name with HealthEquity.
I have read, understand, and accept my obligations under the HSA Custodial Agreement.
I certify that I am eligible to open and contribute to an HSA

Subscriber First Name

Subscriber Last Name

Subscriber Signature

Date (MM/DD/YY)

Fair Treatment Notice

SelectHealth obeys Federal civil rights laws. We do not treat you differently because of your race, color, ethnic background or where you come from, age, disability, sex, religion, creed, language, social class, sexual orientation, gender identity or expression, and/or veteran status.

We provide free:

> Aid to those with disabilities to help them talk with us. This may be sign language interpreters or info in other formats (large print, audio, electronic).

> Help for those whose first language is not English, such as interpreters or member materials in otherlanguages.

Need help? Call SelectHealth Member Services at 800-538-5038.

If you feel you’ve been treated unfairly, call SelectHealth 504/Civil Rights Coordinator at 1-844-208-9012 (TTY Users: 711) or the Compliance Hotline at 1-800-442-4845 (TTY Users: 711). You may also call the Office for Civil Rights at 1-800-368-1019 (TTY Users: 1-800-537-7697).

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Health Savings Account (HSA) Enrollment Form

A. HSA ENROLLMENT

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C. SIGNATURE

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Health Savings Account (HSA) Enrollment Form

A. HSA ENROLLMENT

B. COVERED MEMBERS

C. SIGNATURE

Fair Treatment Notice

NOTICES

OTHER LINKS

ABOUT US

CONTACT US