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C FORM 5281WA - Page 1 of 5 Rev. 7/14 WW0714EERLNRL F5281. XWA0EN07140105 Date D SECTION 2 - PLAN SELECTION Regence HSA Healthplan 2. 0 Innova Regence ActiveCare The Everett Clinic MEDICAL No Medical Health Savings Account I have elected Regence HSA Healthplan coverage and would also like an integrated HSA with HealthEquity. Com or by contacting Regence Customer Service at the number provided on my ID card. I may change the e-mail address for receipt of notice of electronic distributions or...
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