You can complete many transactions for your HSA online. For those you can't, use the following forms and follow instructions printed on them.

Name Change Notification form (PDF)
Use this form to make corrections to your name or notify us that your name has changed.

Information Authorization form (PDF)
Use this form to give OptumHealth Bank permission to share your personal and account information with another individual.

Designation of Beneficiary form (PDF)
Use this form to specify who should receive the funds in your HSA when you die.

IRA Rollover/Transfer Request form (PDF)
Use this form to rollover or transfer funds from an IRA.

Customer Request Account Closure form (PDF)
Use this form if you decide to close your HSA with OptumHealth Bank.

Contribution/Deposit form (PDF)
Use this form when you send in contributions, including contributions from your friends and family, with a check.

Transfer of Funds – ACH Deposit form (PDF)
Use this form to transfer funds to your HSA from a bank account at another financial institution.

Additional Debit Card Request form (PDF)
Use this form to request an OptumHealth Bank Health Savings Account Debit MasterCard® for your spouse or a dependent.

Debit Card Dispute form (PDF)
Use this form to report unauthorized activity on your Debit MasterCard or charges you believe to be incorrect.

ACH Dispute form (PDF)
Use this form to dispute an ACH withdrawal from your account.

Withdrawal/Distribution form (PDF)
Use this form to request a distribution from your account, to have excess contributions returned to you or to reimburse yourself or pay a provider for a qualified expense.

Withdrawal Correction form (PDF)
Use this form to redeposit funds withdrawn in error from your account.

Transfer of Funds – ACH Withdrawal form (PDF)
Use this form to request a distribution from your account for qualified medical expenses you paid for out-of-pocket.

Statement Delivery Change Request form (PDF)
Use this form to request that your statements be delivered by mail.

HSA Rollover/Transfer Request form (PDF)
Use this form to authorize the transfer of HSA funds from another custodian to OptumHealth Bank.

Employer Contribution form (XLS)
Submit this form with a check to make contributions to employees' HSAs