Healthcare Savings Program

HEALTHCARE SAVINGS PROGRAM

Enrollment Information

Participant Name:   Date of Birth:

Insurance Information

Medical History (for eligibility and claims)

Program Election

Select Program Type (check all that apply):

Health Savings Account (HSA)

Flexible Spending Account (FSA)

Health Reimbursement Arrangement (HRA)

Payroll Deduction Authorization:

I authorize payroll deductions for the elected contribution amount.

Beneficiary Designation

Designate one or more beneficiaries for funds held in the program. If multiple are named, indicate percentage allocation that totals 100%.

Reimbursement and Claims

Reimbursement requests must be submitted with substantiating documentation demonstrating that expenses are eligible under the elected program. The Plan Administrator reserves the right to require additional documentation and to deny reimbursement for claims lacking adequate proof.

Reimburse via payroll    Reimburse by check    Direct deposit

Privacy, Authorization, and Acknowledgment

By enrolling, the Participant authorizes the Program Administrator and its agents to obtain and use medical and insurance information as necessary to determine eligibility, process claims, and administer the program. The Participant acknowledges receipt of the program privacy practices and consents to the use and disclosure of protected health information for plan administration, billing, and claims adjudication.

I acknowledge receipt of the privacy practices and authorize use of medical information as described above.

Authorization Expiration Date:

Program Terms and Conditions

Eligibility: The Participant represents and warrants that the information provided is true, complete, and accurate. The Participant affirms they meet the program eligibility criteria and will promptly notify the Plan Administrator of any change in status that affects eligibility.

Contributions & Tax Treatment: Contributions to the selected program are subject to program rules and applicable tax treatment. The Participant acknowledges that tax consequences may result from contributions, reimbursements, or distributions and that the Plan Administrator does not provide tax advice.

Forfeiture and Termination: Unused funds may be subject to forfeiture or rollover consistent with the specific program selected. The Plan Administrator reserves the right to modify or terminate program features at any time, subject to applicable law and plan provisions.

Documentation and Audits: The Participant must retain receipts and supporting documentation for all reimbursement claims. The Plan Administrator may audit claims and require repayment of any amounts improperly reimbursed.

Limitation of Liability: To the extent permitted by law, the Plan Administrator and its agents are not liable for tax obligations, penalties, or other liabilities arising from Participant actions or failure to comply with program rules.

Amendment: The Plan Administrator may amend program rules, contribution procedures, reimbursement processes, and participant responsibilities as necessary for administration and compliance.

Certification

I certify under penalty of perjury that the information provided on this Enrollment Form is true and correct to the best of my knowledge. I authorize payroll deductions where elected and permit the Plan Administrator to use and disclose necessary information to administer my participation. I understand that knowingly making a false statement may result in denial of benefits and other legal remedies.

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