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Welcome to BASIC

BASIC HSA Administrative Forms

Throughout the Plan Year:

BASIC HSA Guide for Participants
Click here to open

HSA Enrollment Forms
Employees use this form to elect the amount they would like to have payroll deducted to contribute to their existing HSA account.

2020: Click here to open

Fifth Third Bank HSA Application
New HSA Accounts at Fifth Third Bank are opened using this application.

2020: Click here to open

HSA Participant Information Change Form

Complete this online form if an employee has a status changes such as an increase in election, change in per pay, termination of coverage or address change.
Click here to open

2020 HSA Employer Renewal Materials:

Return these forms to BASIC to complete your HSA Renewal:

  1. HSA Enrollment Spreadsheet
  2. HSA Renewal Wizard

HSA Information for your reference:

Enrollment Tools: