Hsa Durable Power Of Attorney Form

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HSA DURABLE POWER OF ATTORNEY FORM
Account Holder Instructions
To establish Power of Attorney complete this form and send the ORIGINAL with notary signature on the
form to The Bank of New York Mellon (BNY Mellon) at the address below. By designating a Durable
Power of Attorney for your HSA account you authorize BenefitWallet to interact with named
person as though it were you, the account holder.
Your Power of Attorney will remain in effect until revoked by you in writing.
Note: Account statements are downloadable online at
Send this completed and signed form (not a copy) to BNY Mellon at:
Mail:
Courier/Overnight:
BenefitWallet
BenefitWallet
th
P.O. Box 1584
500 Plaza Drive 8
Floor
Secaucus, NJ 07094-1584
Secaucus, NJ 07094
June 2013 (Version 2.0)

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