Election Change Form For The Health Savings Account (Hsa) Form
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1P.O. Box 43653 Louisville, KY 40253-0653 (502) 244-1161 (800) 919-BMSI
FAX (502) 244-1162
ELECTION CHANGE FORM FOR THE HEALTH SAVINGS ACCOUNT (HSA)
Employer_______________________________________ Employee Name_______________________________________
Social Security # _________________________________
Date of Birth ___________________________________
Home Address _______________________________________City ____________________State_________ Zip_________
Home Phone (_____) _______________________________ E-mail (required) ___________________________________
1
OPTION
HEALTH SAVING ACCOUNT ELECTION CHANGE FORM – Annual/Per Pay Change
This option is available only to those Employees who have established a Health Savings Account and have completed
applicable Applications and paperwork for proper establishment of a qualified HSA.
YES I elect to CHANGE my PLAN YEAR ELECTION from $___________ (current election) to
$___________ for the REST OF THE PLAN YEAR. (Please calculate based on the number of
pays LEFT in your Plan Year. See HR/Payroll for this information.)
This will CHANGE my PER PAY ELECTION/CONTRIBUTION from $__________ (current
election) to $___________ per pay period.
(THIS IS THE PER PAY ELECTION AMOUNT.)
****MUST COMPLETE: DATE OF PAYROLL CHANGE: _____________________________
(NOTE: Make sure your change is not exceeding the statutory IRS Maximum for contribution to an HSA. Ask BMS for these
details.)
2
OPTION
HEALTH SAVING ACCOUNT ELECTION CHANGE FORM – One Time Change
YES I elect to make a ONE TIME CONTRIBUTION of $___________ to be added to my current
Plan Year Election.
****MUST COMPLETE: DATE OF PAYROLL CHANGE: _____________________________
(NOTE: Make sure your change is not exceeding the statutory IRS Maximum for contribution to an HSA. Ask BMS for these
details.)
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
IF EMPLOYER IS CONTRIBUTING TO THE HSA: The Employer has elected to CHANGE
ELECTION to $____________for the PLAN YEAR which is $________ per pay period.
(Must be completed by the Employer if applicable to Plan Set-Up.)
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Reminder: The Health Savings Account allows for participants to pays for qualified healthcare expenses covered by the High Deductible Health
Plan (HDHP) as described in IRS Code Section 223. 1.) I understand that I can only participate in this Plan if I am currently enrolled in my
Employer’s HDHP/HSA Health Plan. 2.) I understand that I am not entitled to Medicare Benefits. 3.) I understand that the HDHP Plan must meet
minimum requirements and deposits cannot exceed the indexed maximums outlined by the IRS.
I agree to follow all rules and regulations as
outlined by the IRS with respect to HSA Account and I understand I must complete any applicable Custodial Bank Applications in order to establish
my HSA Account with an IRS approved Custodian.
My employer and I agree that my taxable income will be reduced during the year by an equal portion of the benefit elections (1-2) set forth above
and that qualified expenses will be paid on a tax-free basis, I understand that I may change my election only in the event of certain changes in my
status and that, prior to the first day of each Plan Year, I will be offered the opportunity to change my benefit election for the upcoming Plan Year. I
have also read and understand the Important Information provided with enrollment materials.
Employee Signature: ______________________________________________________________Date_______________________________
Plan year start (mm/dd/yy) _____/______/_____ and end _____/_____/_____
TO BE COMPLETED BY EMPLOYER
First payroll start date _____/____/_____ Pay Cycle ___________________
;OYER
Custodial HSA Application Submitted with this Election Form____________(new accts. only)
02/11 version
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Parent category: Medical