Forms & Documents-old - Indiana University

HSA

Health Savings Account

A Health Savings Account (HSA) is a pre-tax benefit used to pay for eligible medical, dental and vision expenses that works in combination with a qualified High-Deductible Health Plan. With an HSA, employees can invest their benefit dollars to help save for retirement.

Forms

Additional Debit Card Request Form

This form allows you to request replacement or additional Benefit cards.

Authorization to Disclose Information Form

This form authorizes Nyhart to disclose Personal Health Information and/or Transactional Information to an authorized person of your choice.

HSA Beneficiary Change/Spousal Consent Form

Use this form to designate or change your beneficiary. If you are married use this form to designate your spouse as Primary Beneficiary or get their signature of consent for another primary beneficiary.

HSA Contribution Form

This form allows you to make a normal contribution, mistaken distribution, or rollover contribution to your HSA. Mistaken Distributions have to be submitted by December 29th to guarantee they will be processed by December 31st.

HSA Death Distribution Request Form

This form authorizes a distribution from a deceased HSA holder’s account.

HSA Direct Deposit Authorization Form

This form allows you to initiate, update, or terminate direct deposit reimbursement from your HSA.

HSA Distribution Request Form

Use this form to request a distribution from your HSA for Normal/Disability/Prohibited transaction distribution, excess contribution removal, rollover/transfer.

HSA Enrollment/Change Form

This form allows the individual to change their enrollment.

HSA Power of Attorney Form

This form grants Power of Attorney to a designated individual over your HSA. It must be notarized.

HSA Transfer Form

This form is used to initiate a direct transfer from your HSA with another custodian to the Nyhart HSA.

FSA

Flexible Spending Account

The Flexible Spending Account (FSA) is a pre-tax flexible spending account benefit. IU offers the Healthcare FSA that is used to pay for eligible medical, dental and vision expenses; a Healthcare Limited FSA (compatible for use in combination with a Health Savings Account) that is used to pay for eligible dental, vision and post-deductible medical expenses; and a Dependent Care FSA that is used to pay for eligible day or evening care expenses for eligible dependents.