HSA FORMS

PORTAL QUICKSTART

A guide to navigating your consumer portal, including updating personal information; making contributions, investments, and distributions; and updating bank information.

CONTRIBUTION FORM

Change your contribution election amount or submit a new contribution.

DISTRIBUTION FORM

Request a distribution paid to you or directly to a provider.

BENEFICIARY FORM

Elect one or more beneficiaries for your account.

DEBIT CARD REQUEST

Request a replacement or additional debit card. (Standard fees apply.)

INFORMATION CHANGE

Update your contact or personal information. Additional documents may be required to authorize change.

INFORMATION AUTHORIZATION

Update who can access information about your account.

POWER OF ATTORNEY

Designate or revoke power of attorney over your account.

POWER OF ATTORNEY, DISABILITY

Designate or revoke power of attorney due to disability.

DEATH DISTRIBUTION

Request a death distribution for a deceased accountholder. Additional documentation required.

DIRECT DEPOSIT FORM

Submit bank information to allow direct deposit directly to and from your account.

PAYROLL ELECTION

Update your payroll election for HSA. Submit this form to your employer rather than to Erisa.

1200 San Pedro Dr NE
Albuquerque, NM 87110

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