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15-520 8/15 When to apply Application received Between the 1st and 15th of the month Effective date The 1st of the following month The 1st of the next following month Keep in mind if you apply before December 16 2015 your effective date will be January 1 2016. Note This form is not required as part of your application for a HSA health plan. Yes I would like to open a HSA with BenefitWallet. Otherwise do not fill out this form. Request for a Health Savings Account HSA For HAP Personal...
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