HSA withdrawal correction form
This form can be used to redeposit funds withdrawn in error and cannot be used to correct an Excess Contribution Return. Funds will be posted as a correction and not as a contribution. The deposit will be entered for the year the distribution occurred.
Questions? Please call us at the number on the back of your debit card if you have any questions while completing this form.
Important Note: Please do not provide any card information on this form as forms with debit card numbers will not be processed and will be destroyed for your protection.
Related resources
How to use an HSA
Learn how to make deposits to and withdrawals from your health savings account (HSA).
Manage your HSA contributions
Are you taking full advantage of all your HSA's tax benefits by contributing the maximum each year?
Qualified medical expense tool
Use our qualified medical expense tool to filter by account type and expense type to see if it qualifies.
Top