Form Ms-04-1598 - Health Savings Account Bank Notification Form printable pdf download

Health Savings Account Bank Notification Form

Oxford Health Insurance •

Mailing Address: 14 Central Park Drive, Hooksett, NH 03106 • Attn: Group Enrollment Department

Introduction

If you are selecting an Oxford HSA qualified Health Plan, your employees are eligible to enroll in a Health Savings Account (HSA).

This form must be submitted with your Oxford Group Application.

My group would:

Like Oxford’s preferred partner, Exante Bank, an affiliate of Oxford Health Plans, to administer the HSA for our employees.

Like to use our own financial institution to administer the HSA. Who is your preferred financial institution?

_________________________________________________________________________________________________

Employer Name: ______________________________________________________________________________________________________

Employer Address: ____________________________________________________________________________________________________

____________________________________________________________________________________________________

City, State: ______________________________________________________________________ Zip Code: ____________________________

If you have selected that you would like Exante Bank to administer the HSA for your employees, please fill out the following form.

(All fields are required.)

Section I: Employer Benefit Contact Information

Name: ________________________________________________________________________________________________________________

Phone: ________________________________________________________________ Fax: ________________________________________

Title: ________________________________________________________________________________________________________________

E-Mail: ______________________________________________________________________________________________________________

Contact for Monthly/Yearly Employer Reports (If different from Employee Benefit Contact)

Name: ________________________________________________________________________________________________________________

Phone: ________________________________________________________________ Fax: ________________________________________

Title: ________________________________________________________________________________________________________________

E-Mail: ______________________________________________________________________________________________________________

Oxford contact:

___________________________________________________________________________________________________

MS-05-257

7423 R1

Form Ms-04-1598 - Health Savings Account Bank Notification Form