Get the free HSA and HSA Compatible FSA Enrollment/Change Form

This form is used by employees to enroll or make changes to their Health Savings Account (HSA) and Flexible Spending Account (FSA) contributions, including contribution amounts and beneficiary designations.

How to fill out hsa and hsa compatible

How to fill out HSA and HSA Compatible FSA Enrollment/Change Form

1. Obtain the HSA and HSA Compatible FSA Enrollment/Change Form from your benefits administrator or website.
2. Fill in your personal information, including your name, address, and Social Security number.
3. Indicate whether you are enrolling in a Health Savings Account (HSA) or a Health Flexible Spending Account (FSA).
4. Specify the amount you wish to contribute to your HSA or FSA for the upcoming year or pay period.
5. Review the eligibility requirements for contributions to ensure you qualify for an HSA.
6. Sign and date the form at the bottom to certify that the information provided is accurate.
7. Submit the completed form to your employer's HR department or benefits administrator.
8. Keep a copy of the submitted form for your records.

Who needs HSA and HSA Compatible FSA Enrollment/Change Form?

1. Employees who wish to enroll in or make changes to their Health Savings Account (HSA) or Health Flexible Spending Account (FSA).
2. Individuals who are eligible for HSAs and want to maximize their healthcare savings.
3. Those who have changes in their employment status, family situation, or healthcare needs that require an update to their contribution amounts.

People Also Ask about

Can I change my FSA to HSA?

Although FSA accounts are compatible with any health plan, HSAs require simultaneous enrollment in an HSA-eligible, high-deductible health plan (HDHP). If your health coverage changes, you may change from an FSA in one plan year to an HSA in the next, or vice-versa.

What happens to my FSA if I don't use it?

Internal Revenue Service (IRS) rules clarify that you can't contribute to a Health Savings Account (HSA) and a Flexible Spending Account (FSA) in the same plan year.

Can you have an HSA and dependent FSA?

A Dependent Care FSA does not affect your eligibility for an HSA. You can have both accounts without creating any conflict of benefits.

Can I contribute to an HSA if I had an FSA?

Bottom line: Both HSAs and FSAs provide financial benefits for managing health care expenses. HSAs offer more flexibility and long-term growth potential, making them a valuable tool for future financial planning. Learn about HSA options from Aetna.

Can I enroll in an HSA and FSA at the same time?

The money that you contribute to a dependent care FSA lowers your taxable income for the year, but you must use the funds within a specified period of time. You can contribute to a health savings account (HSA) and dependent care FSA at the same time.

How do I change my FSA to HSA?

Under IRS rules, you cannot actively enroll in and contribute to a General-Purpose FSA account and an HSA account simultaneously. Because of that, when switching from an FSA to an HSA it's best to make a “clean break” by spending down your FSA balance to $0 before the HSA plan year begins.

What happens if I contribute to HSA and FSA in the same year?

You can't have a healthcare FSA and an HSA at the same time, since they're both used to pay for the same types of expense—your medical costs [2]. However, you can have a limited-purpose or dependent care FSA and an HSA simultaneously.

For pdfFiller’s FAQs

What is HSA and HSA Compatible FSA Enrollment/Change Form?

HSA stands for Health Savings Account, which is a tax-advantaged medical savings account available to taxpayers in the United States. An HSA Compatible FSA (Flexible Spending Account) Enrollment/Change Form is a document used by individuals to enroll in or make changes to their HSA and compatible FSA.

Who is required to file HSA and HSA Compatible FSA Enrollment/Change Form?

Individuals who want to open or modify their HSA or HSA Compatible FSA are required to file this form. This typically includes employees participating in a high-deductible health plan (HDHP) who wish to take advantage of tax benefits associated with HSAs.

How to fill out HSA and HSA Compatible FSA Enrollment/Change Form?

To fill out the form, individuals should provide personal information such as their name, address, and Social Security number, select the type of enrollment or change they are requesting, and indicate their contribution amounts. It's also important to sign and date the form before submitting it.

What is the purpose of HSA and HSA Compatible FSA Enrollment/Change Form?

The purpose of the form is to officially document and process an individual's enrollment in or modifications to their HSA and compatible FSA, ensuring that they can benefit from the associated tax advantages and healthcare expense management.

What information must be reported on HSA and HSA Compatible FSA Enrollment/Change Form?

The form must include personal information such as the individual's name, contact details, Social Security number, account information, and any changes to contribution amounts or enrollment types. It may also require information regarding their high-deductible health plan.