HSA and FSA Online Services

Forms

Health Savings Account (HSA) Death Beneficiary Change 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.

Health Savings Account (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.

Health Savings Account (HSA) Death Distribution Form

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

Health Savings Account (HSA) Distribution Request Account Closure Form

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

Health Savings Account (HSA) Transfer Request Form

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

Health Savings Account (HSA) Blocked Account Verification Form

Use this form to validate your identity when opening an HSA. In accordance with the USA PATRIOT Act, federal law requires WEX to obtain, verify, and record information that identifies each individual or entity opening an HSA. You can upload the necessary documentation via your online account or the mobile app.

Forms

Dependent Care Worksheet

Claim Form

This form allows you to request reimbursement from your Flexible Spending Account.

Medical Necessity Form

Use the Medical Necessity Form when requesting reimbursement for dual-purpose expenses. Per IRS regulations, dual-purpose expenses are eligible only if recommended by a medical practitioner, as they have both a medical purpose and a personal, cosmetic, or general health purpose.

Dependent Care Verification Form

Use the Dependent Care Verification Form after dependent care expenses have been incurred and in place of an itemized statement or receipt. This form must be completed by your dependent care provider. This form does not replace the need to submit a dependent care claim. Rather, it is intended to accompany your dependent care claim and serve as a substitute for the documentation required to substantiate that claim. No reimbursements will be made if this form is not uploaded to a claim or accompanied by the appropriate form. Upload this form to your claim in your online account or include it with a Claim Form.

Recurring Dependent Care Request Form

Use this form each plan year and as changes occur to receive recurring reimbursements for dependent care expenses.

Deductible Verification Form

Use this form if you are enrolled in a healthcare limited flexible spending account and you’ve met the IRS statutory deductible. A completed form must be on file in order for you to be reimbursed for eligible general-purpose medical expenses. Until then, only expenses for dental, vision, and preventive care are eligible for reimbursement.