HSA Benefits

HSA Features

Who is Eligible

What is Covered

Forms

FAQs

Health Savings Account Forms
To apply for, and make changes to, your HSA, please use these convenient online forms. 

Please Note: These forms may be filled out electronically by clicking in each field and typing in the information.   Once the form is completed, hit your print key and make two copies; one to submit to the bank, and one for your records. 

Or, if you prefer, you may still print the forms blank and fill them out with a pen. Any questions, please feel free to contact us. 

THE USA PATRIOT ACT REQUIRES IDENTITY VERIFICATION FOR ALL NEW ACCOUNTS
 
To help the government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account.  What this means for you:  When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you.  We may also ask to see your driver’s license or other identifying documents.

When filling out the HSA Application, use your name where it asks for beneficiary.

Account Opening Documents (Required):

HSA Customer Checklist (PDF)

Health Savings Account Application (PDF)

Authorization for Preauthorized Debit (PDF)

Other Forms:

HSA Designation of Death Beneficiary  (PDF)

HSA Transfer Request  (PDF)

HSA Rollover Certification (PDF)

HSA Contribution/Investment Form (PDF)

HSA Withdrawal Statement (PDF)

HSA Eligibility and Information (PDF)

PDF File Information

Adobe® Acrobat® Reader™ is free software for viewing and printing Adobe PDF files. This software that lets you view and print Adobe Portable Document Format (PDF) files on all major computer platforms, as well as fill in and submit PDF forms online.

It is likely that the Acrobat Reader is already installed on your computer, but if you find that you cannot read the newsletter files, it is very easy to download the software and install it.

Checklist

1. Complete the checklist
2. Enclose your signed forms and check payable to:
   
           Home Federal Savings Bank
           ATTN: HSA Administrator
          1016 Civic Center Drive NW
          PO Box 6057
          Rochester, MN 55903-6057
   
3. You will receive a welcome letter along with other account information upon receipt of your application

For lost or stolen personal check cards,
call 1-800-383-8000