HSA and FSA Online Services

Forms

Additional Debit Card Request Form

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

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 WEX Inc. HSA.

Forms

Additional Debit Card Request Form

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

Dependent Care Worksheet

FSA Claim Form

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

FSA Direct Deposit Form

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

Mileage Reimbursement Form

This form must be completed for mileage reimbursement.