Healthcare HSA Highlights

HEALTHCARE HSA HIGHLIGHTS

Patient Information

Patient Name:    Date of Birth:    Gender:

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Insurance & HSA Account Information

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Medical History (for contact and coordination only)

Highlights — Legal Summary and Participant Responsibilities

Purpose: This document summarizes key features of a Health Savings Account (HSA) associated with a High Deductible Health Plan (HDHP). It is a summary only and does not supersede the HSA Custodial Agreement, plan documents, or applicable tax law. The participant is responsible for determining eligibility and compliance with tax rules governing contributions, distributions, and qualified medical expenses.

Eligibility: To contribute to an HSA an individual must be covered by a qualifying HDHP and must not be covered by non-HDHP health coverage that disqualifies HSA eligibility. Participant affirms responsibility to verify eligibility and to cease contributions when eligibility terminates.

Annual Contribution Limits: The maximum pre-tax contribution for the current plan year is $ . Catch-up contributions (age 55+) allowable: $ . Actual limits are set by tax law and may change annually.

Employer Contributions: Any employer contribution to the HSA is reflected on the participant's account and may be subject to plan rules. Employer contribution amount for the period indicated: $ . Employer contributions may be subject to vesting and plan terms.

Qualified Medical Expenses: Distributions used to pay or reimburse qualified medical expenses are tax-advantaged. Participant must retain documentation substantiating distributions and expenses. The HSA custodian may require receipts for distributions. Non-qualified distributions may be taxable and subject to penalties.

Rollovers and Portability: HSAs are individually owned accounts and are portable. Rollovers from other HSAs and trustee-to-trustee transfers are subject to rules. Participant accepts responsibility to consult plan documents and tax guidance for rollover procedures and limits.

Coordination with FSAs/HRAs: Certain health flexible spending arrangements (FSAs) and health reimbursement arrangements (HRAs) can affect HSA eligibility. Participant must disclose other account types to determine compatibility.

Tax Reporting: The participant is responsible for accurate tax reporting of contributions and distributions. The HSA custodian will provide required tax reporting forms as mandated by law. The participant agrees to retain records sufficient to support HSA distributions as tax-free.

Documentation and Audit: The participant acknowledges that the HSA custodian, plan administrator, or authorized designee may request documentation to substantiate account activity. Failure to provide substantiation may result in reversal of tax-free treatment or account adjustment.

Termination of Eligibility: If an individual becomes ineligible for HSA contributions, the participant must cease contributions and notify the plan administrator. Distributions for qualified medical expenses may continue subject to account balance and custodian rules.

Elections and Acknowledgments

Contribution Election: By signing below, participant elects to contribute to the HSA as follows for the current plan year:

Catch-up election (if age 55 or older): I affirm I am age 55 or older and elect catch-up contributions.

Electronic Statements and Communication: I consent to receive HSA account statements, tax forms, and communications electronically where permitted.

HIPAA / Privacy Acknowledgment: I acknowledge receipt of the Notice of Privacy Practices for the HSA custodian and understand how my protected health information may be used and disclosed in relation to account administration.

Authorization Expiration Date: This election and authorization remain effective until revoked in writing or until the expiration date indicated:

Certification

By signing below I certify under penalty of perjury that I meet the eligibility requirements for HSA contributions, that the information provided on this form is true and correct to the best of my knowledge, and that I understand my responsibilities regarding contributions, distributions, and tax reporting. I acknowledge that this document is a summary of HSA features and does not modify the terms of the HSA Custodial Agreement or plan documents.

I understand I must retain receipts and records of qualified medical expenses and that incorrect or non-qualified distributions may result in tax liability and penalties under federal and applicable state law. I authorize the release of information necessary to administer my HSA and verify eligibility.

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