HSA forms and documents

Use the tabs below to find forms and documentation related to your Everence HSA.

Select the appropriate tab below

  • New accounts
  • Existing accounts
  • Employers
New accounts

HSA and Everence Federal Credit Union Membership Application

HSA Disclosure Statement and Custodial Agreement 

HSA Eligibility Worksheet

HSA Contribution Form

HSA Distribution Request Form 

Eligible Expenses for HSA

Investment HSA Terms and Conditions

Existing accounts

HSA Debit Card Application1 

HSA Maintenance Form

HSA Contribution Form

HSA Distribution Request Form 

Direct Transfer or Rollover of MSA or HSA Funds

Transfer of IRA Funds to an Everence HSA

Request for Return of HSA Excess Contributions

Request to Close HSA

Eligible Expenses for HSA

Investment HSA Terms and Conditions

Employers

Everence Federal Credit Union HSAs – A Summary for Employers

HSA Group Contributions 

Open a Health Savings Account

Contact our National Branch for assistance with HSA requests.

Everence Federal Credit Union

Attn: HSA department
2160 Lincoln Highway E., Suite 20
Lancaster, PA 17602

Toll-Free: 800-451-5719
Phone: 717-735-8330
Fax: 717-735-8331
Text: 717-735-8332

Email: infocu@everence.com

Download the app: App Store | Google Play

Find an Everence Federal Credit Union branch, shared branch, or fee-free ATM near you.

Disclosure

1 When applying for an HSA debit card, please read the HSA debit card disclosure.