Individual, Not Part of Employer Group

If you are an individual associated with an employer group, go to Individual, Part of an Employer Group and enter the username and password provided by your employer to complete your HSA enrollment. If you are not associated with an employer group and want to sign up for a health savings account, please proceed to complete the enrollment form below.

Required Information

Personal Information

First Name:	M.I:	Last Name:	Suffix:	Gender:
				Male Female

Date of Birth:

Identification Type:	ID Number:

Address:	City:

State:	Zip:

Daytime Phone Number:	Email:
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Note: To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify and record information that identifies each person who opens an account. What this means to you: When you open an account we will need you and your authorized signer to provide name, street address, date of birth and other information that will allow us to identify you and your authorized signer. We may also ask to see your driver's license or other identifying documents. If your identity cannot be authenticated, or your application is incomplete, your account will be opened in a frozen status.

Health Plan Information

Insurance Carrier:	Effective Date of High Deductible Health Plan

Type of Coverage	Enter the deductible amount of your high deductible health plan:

HSA Account Options

Select the account options you would like for your account. After you have made your selections, continue to the next step.

Plans

Standard Value

Initial Contribution
Account Setup Fee
Monthly Maintenance Fee (Two months fees collected at signup)
Initial Contribution (Minimum Contribution is $100)
Total Amount to initiate Account

Order Debit Card
	Check this box if you want to order one MasterCard debit card to pay for HSA qualified healthcare expenses with your HSA funds. The card will be issued in your name. Once your account is set up, additional dependent cards can be ordered. Cards will be mailed in 5-7 business days.

Payment Account Information

Amount to be deducted from the account:
Bank Name:	Account Type:
	Checking Saving
Routing Number:	Account Number:

Sign up for Online Access

You must enter a username and password for your account if you choose this option. Usernames and passwords must be at least 6 and no more than 24 characters. Any combination of letters and numbers can be used. Usernames and passwords are case sensitive. You will get a confirmation email upon successful creation of your account. Click on the confirmation email link in order to activate your online account. By signing up for online account access, you agree to all terms and conditions as indicated in our Electronic Access Agreement
User Name:	Password:

	Password Recommendation (?) Must be between 8 to 18 characters. Contains 1 uppercase letter. Contains 1 lowercase letter. Contains 1 special character : ~!@#$%^&*+=`\|\{}()-_[]:;"'<>,.?/ Contains base 10 number (0-9). Cannot contain in full or partial your username. Cannot be the same as Old Password.
Password Reminder Question:	Confirm Password:

Password Reminder Answer:

Dependent Information

You are allowed two(2) cards per account at no cost. Additional cards ordered will have a charge of $10.00 each. Dependent(s) must be 18 years or older for a debit card.

Add Another Dependent
First Name:	Last Name	Gender	Relation

SSN	Date of Birth	Debit Card Request
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Beneficiary Information

Add Another Beneficiary
First Name:	Last Name	Relation	Primary/Contingent	Distribution

Important Information About Electronic Records and Your Health Savings Account

By creating your account online, you agree to accept Account Enrollment Documents in electronic format. The Account Enrollment Documents consist of the two (2) following documents: Electronic Access Agreement and Administrative Services Agreement. Important information in these documents will be provided to you online. If you wish to save the information provided, you will need to save it electronically to your computer or print it out yourself.

I have read the documents associated with establishing my HSA account with Sterling Health Services and transacting business online. I accept the terms of the agreements.