DescriptionClear Save Print You can complete this form online and print it, or print it out first and complete by hand. Then, fax or mail it to the number or address below. This form works best with Acrobat Reader 7.0 ® or above. Fidelity HSA® Supplemental Debit Card Application and Authorization and Indemnification Form Use this form to enable an eligible spouse and/or dependent(s) to have a Supplemental Debit Card to...
Form was Filled by