Employee HSA Payroll Deduction Form

Return completed forms to:

New Mexico State University

Attn: Benefit Services

Fax: 575-646-2806

Email Address:

Employee Information and Authorization
Employee Name: / NMSU Aggie/Banner ID:
Contribution Election: Employee/Self Only Family Eligible for the Catch Up Contribution
(Only available to age 55 or older)
Please withhold $ per paycheck and apply the funds to my HSA.
Any person who knowingly and with intent to defraud any insurance company or other person files a statement containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act.
Signature / Date
HSA Contribution Limits
2012 Annual HSA Contributions
Coverage Type / Annual Maximum*
Self-Only / $3,100
Family / $6,250
*Catch-up contribution (age 55+): additional $1,000/year
Eligibility and contribution limits to your health savings account (HSA) are determined by the effective date of your high-deductible health plan (HDHP). If you’re covered as of December 1, you’re considered an eligible individual for the entire year and you’re not required to pro-rate your contributions. If you cease to be an eligible individual during the next calendar year, any funding over the prorated amount is considered an excess contribution and subject to a penalty and income tax. For further information or to review eligibility, please contact HealthEquity Member Services at 877.877.3696.
Account Closing Fee / $25.00
Check reimbursement Fee / $2.00 for paper. No fee for electronic fund transfer
Debit card replacement/additional card (3 free) / $5.00 each additional if lost, stolen, or damaged
Excessive contribution Refund Request / $20.00
Monthly paper account statement mailed / $1.00 per monthly statement. No fee for electronic statements
Ongoing individual fee(if you keep account after leaving the state plan) / $3.95
Overdraft or Insufficient Funds / $20.00 per item
Return deposited item / $20.00 per item
Stop check services / $20.00
Stop payment request / $20.00 per item
Investments / No fee

For HR Use Only

9 month 12 month / Annual Contribution Amount: / Effective Date:


Health Savings Account Authorization Form

SONM HDHP GR002191

Qualifying for a Health Savings Account

This enrollment form is to open a health savings account (HSA) that is used to accumulate assets for the payment of qualified healthcare expenses. Your HSA is your financial asset even if you change employers or health plans. To open an HSA you must meet three criteria:

1) You must be covered by a qualified high deductible health plan.

2) You cannot be covered by another health plan, including Medicare.

3) You cannot be claimed as a dependent on another individual’s tax return.

Personal Information
First Name / M.I. / Last Name
Subscriber ID Number (located on your Presbyterian medical ID card or billing invoice): / Date of Birth (mm/dd/yyyy)
Insurance Company
Presbyterian Insurance Company
Authorization and Certification
• HealthEquity has partnered with Presbyterian Insurance Company to administer a fully integrated Health Savings Account (HSA). The term fully integrated refers to the process in which Presbyterian Insurance Company will send HealthEquity medical and prescription claim information for all enrolled subscribers who participate in a HSA. Claims data for enrolled dependents will also be shared but claim information for dependents age 12 and older will only include date and dollar amount unless the enrolled dependents elect to release complete claim information by executing HealthEquity’s Dependent Health Information Authorization Form. To obtain this form, contact HealthEquity at 1-877-877-3696. This information is shared to assist you in paying and tracking healthcare claims.
• Your signature below indicates that you agree to the following:
o To participate in a HSA administered by HealthEquity for you (the subscriber) and any of your enrolled dependents.
o You (the subscriber) understand and have explained to your dependents that claim detail for all enrolled members will be released by Presbyterian Insurance Company to HealthEquity.
o Claim data will be viewable on the password protected HealthEquity website.
• I accept the terms of the HealthEquity HSA enrollment form and the HSA Custodial Agreement. The HSA Custodial Agreement is available by clicking on “Forms and Documents” in the Resource Center on www.healthequity.com.
• I acknowledge that this account will be established according to the custodial agreement that is between the custodian and me, the account holder. I understand that Presbyterian Insurance Company is not a party to this agreement.
• In compliance with the USA PATRIOT Act, HealthEquity must verify the identity of all customers seeking to open an HSA. As part of this identity verification process, you may be asked to provide additional information and/or documentation before your account can be established.
Print Name / Signature / Date

Please expect a delay in access to HSA funds for new enrollments due to processing timelines.

The balance in your HSA is insured by the Federal Deposit Insurance Corporation (FDIC), subject to applicable deposit limits.

Presbyterian_HSA_Authorization_Savvy_100_Form_20120404