If you have elected to have pre-tax dollars deducted from your paycheck to be contributed into a Health Savings Account (HSA), the deductions will not begin until your account is opened and you have completed this form. Likewise, you will forfeit the employer contribution until your account is open and ready to receive funds. It is your responsibility to open your HSA, as your employer is not able to do so on your behalf.
Once you receive confirmation that your HSA has been opened, you must complete the form below. Your payroll deduction will begin on the next feasible payroll cycle, no later than 30 days of receipt of this form.
Under IRS regulations governing the Health Savings Account, you may change your pre-tax HSA deduction at any time, providing you are eligible to contribute. If you wish to change your contribution amount, please do so through your online enrollment system.