Healthcare HSA Agreement

HEALTHCARE HSA AGREEMENT

This Healthcare Health Savings Account (HSA) Agreement (the Agreement) sets forth the terms and conditions under which the Account Holder authorizes and directs the HSA Custodian/Administrator to establish, administer and permit use of a Health Savings Account for the payment or reimbursement of qualified medical expenses in accordance with applicable law.

PARTIES AND IDENTIFICATION

Account Holder Name:

Date of Birth:    Gender:

HSA ACCOUNT & ADMINISTRATOR

Effective Date of Account Establishment:

INSURANCE INFORMATION

MEDICAL HISTORY (FOR RECORDS)

TERMS AND CONDITIONS

1. Definitions: For purposes of this Agreement, "Qualified Medical Expense" means expenses eligible for payment or reimbursement from the HSA under applicable tax and benefit law. "Custodian/Administrator" means the entity identified above that holds and administers the HSA funds.

2. Contributions: Account Holder and, if applicable, Employer may make contributions to the HSA subject to statutory limits. The Custodian/Administrator will accept contributions in accordance with its procedures and applicable law. Account Holder acknowledges responsibility to monitor contribution limits and to notify Custodian/Administrator of any excess contributions.

3. Use of Funds; Eligible Expenses: Funds in the HSA will be used solely to pay or reimburse Qualified Medical Expenses for Account Holder and other eligible dependents. Account Holder represents that distributions will not be used for non-qualified expenses and acknowledges that non-qualified distributions may be subject to income tax and penalties.

4. Reimbursement Procedures and Substantiation: Account Holder must provide documentation substantiating that a distribution was used to pay or reimburse a Qualified Medical Expense. Custodian/Administrator may condition reimbursement on receipt of such documentation and reserves the right to deny or reverse a distribution until substantiation is provided.

5. Debit Card, Electronic Transfers and Checks: If the account provides debit card or electronic access, Account Holder authorizes the Custodian/Administrator to permit electronic access in accordance with its operating rules. Account Holder is responsible for safekeeping payment methods and will promptly notify the Custodian/Administrator of loss or unauthorized use.

6. Recordkeeping and Tax Reporting: Custodian/Administrator will report HSA distributions and contributions as required by tax law. Account Holder is responsible for maintaining records necessary to substantiate qualified uses and to correct any reporting errors. Account Holder will indemnify Custodian/Administrator for any liability arising from Account Holder's failure to comply with tax or reporting obligations.

7. Termination: Custodian/Administrator may terminate the HSA in accordance with its policies or as required by law. Upon termination, remaining funds will be distributed to the Account Holder subject to applicable tax consequences.

8. Amendments: Custodian/Administrator may amend administrative provisions of this Agreement to comply with changes in law or for administrative purposes. Material changes affecting Account Holder's rights will be communicated in writing as required by law.

9. Limitation of Liability and Indemnification: Custodian/Administrator is not liable for losses resulting from Account Holder's misuse of funds, failure to provide substantiation, or reliance on tax advice inconsistent with law. Account Holder agrees to indemnify and hold harmless the Custodian/Administrator for claims arising from Account Holder's actions or omissions.

10. Governing Law and Dispute Resolution: This Agreement is governed by the laws applicable to the Custodian/Administrator's principal place of business. Disputes will be resolved by the procedures set forth by the Custodian/Administrator, which may include administrative review and binding arbitration where permitted by law.

AUTHORIZATIONS, CONSENTS AND ACKNOWLEDGMENTS

Account Holder hereby certifies that the information provided in this Agreement is true and accurate, and authorizes the Custodian/Administrator to take actions necessary to open and administer the HSA, including receiving and disbursing funds, obtaining substantiating documentation from health care providers when permitted, and reporting to tax authorities as required.

Electronic Delivery Consent: I consent to receiving account disclosures, statements and tax reporting electronically where allowed by law.

HIPAA Authorization for Disclosure of Health Information: I authorize health care providers and insurers to disclose protected health information to the Custodian/Administrator to the extent necessary for administration of HSA claims and substantiation. This authorization expires on:

Certification of Eligible Expenses: By checking this box Account Holder certifies that any requested distributions are for Qualified Medical Expenses as defined by applicable law.

ADDITIONAL ADMINISTRATIVE INFORMATION

ACKNOWLEDGMENT

By signing below, Account Holder acknowledges receipt of this Agreement, affirms understanding of the responsibilities associated with an HSA, and agrees to comply with the terms contained herein. Account Holder also acknowledges that Custodian/Administrator has made no tax or legal representation beyond administering the account and that Account Holder remains responsible for determining tax consequences of contributions and distributions.

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