Fillable Hsa Transfer Request Form printable pdf download

Hsa Transfer Request Form

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Health Savings Account (HSA)

Transfer Request Form Instructions

(Transferring funds from your Current HSA to your HSA at PayFlex

)

As the owner of your HSA, you must complete Sections 1, 2, and 3 of the enclosed form. Below are a few

reminders as you complete the form. If you have employer or employee payroll contributions, please do not

submit this form until the final contribution has been made.

Section 1:

Be sure to include your Phone Number. We or your current Trustee or Custodian may

have to call you with follow-up questions.

Section 2:

Select only one transfer type.

Section 3:

Include the Account Number for the HSA you will be transferring to PayFlex. Your

current Trustee or Custodian will be able process your request more quickly if they have

all of the information on the form.

Certification and Signature section: Sign and date the form.

Mail the transfer form to:

PayFlex Systems USA, Inc.

HSA Operations

13511 Label Lane, Ste 201

Hagerstown MD 21740

We will sign and forward it to your current custodian. Note: You must already have an HSA with PayFlex

for us to accept this transfer.

This transfer may have tax consequences. Please consult with a tax advisor if you have any questions prior to

completing this form. We will return an incomplete form.

Note: Some Trustees or Custodians may require their own form in addition to this form. Please check

with your current Trustee, Custodian or agent for any specific requirements.

PF-16 (6-15) A

R-POD

Hsa Transfer Request Form

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