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2016 Optum Bank. All Rights Reserved. 30657-052016 Rev. 07/16 HSAs are individual accounts administered or offered by Optum Bank Member FDIC. In order to use this form you must have an Optum Bank HSA. To open an account visit us at www. optumbank. HSA Rollover or Transfer Request 040 CO HSA To expedite your HSA rollover or transfer please work directly with the bank where your HSA funds are currently on deposit. Administrative services provided optumbank. com 11000 Optum Circle Eden Prairie...
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