Hsa Enrollment Form

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HSA ENROLLMENT FORM
Instructions
1.
Complete entire form in order to open a Fifth Third Bank Health Savings Account.
2.
Fax completed form to BASIC HSA Department at 866.472.7672 or
3.
Mail completed form to BASIC, Attn: HSA Department, 9246 Portage Industrial Drive, Portage, MI 49024.
4.
If you have any questions regarding this form, please contact BASIC HSA Department, 800.444.1922, X-243.
Account Holder Information
Last Name
First Name
Middle Initial
Social Security Number
Date of Birth
Mother’s Maiden Name
Marital Status (Single / Married)
Gender (M / F)
Telephone Number
E-mail Address
Street Address (cannot be a PO Box)
City State
Zip Code
Employer Information
Employer Name
Division
Hire Date
Employee ID
Insurance Information
To open an HSA, you are required to meet the following criteria:
Must be covered under a qualified HDHP
Cannot be:
Claimed as a dependent on someone else’s tax return
o
Enrolled in Medicare – but mere eligibility does not disqualify
o
Covered under another non-HDHP unless it’s “permitted insurance” (dental, vision, AFLAC)
o
Insurance Company Name
Plan Start Date
Deductible Amount
HDHP Coverage Level
Self-Only
Family/Other
Authorized Signer(s) Information
Regulations require that only one individual can own an HSA account. The account holder may want his/her spouse or a third party through an Authorized User to use a debit
card and/or write checks. Please complete the section below if you wish to grant an Authorized User this authority.
Last Name
First Name
Middle Initial
Social Security Number
Date of Birth
Mother’s Maiden Name
Marital Status (Single / Married)
Gender (M / F)
Telephone Number
E-mail Address
Street Address (cannot be a PO Box)
City State
Zip Code

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