EMPOWER

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Advanced Flex Plan Administration with the Human Touch

Resources for HSAs

This page provides Employer and participant resources, forms, and guides for Health Savings Accounts (HSA).

This page shows resources to help you administer your EMPOWER HSA. If you would like to view our Enrollment Resources page that has helpful information for enrollment, click the link below.

Table of Contents

Forms

Participant Forms

Name

Description

English

Spanish

Direct Deposit Authorization Form

Add or change an existing bank account to receive reimbursements right to your bank account

HSA Beneficiary Form

Use this form to add or change an HSA beneficiary.

HSA Claim Form

Use this form to submit an HSA claim.

HSA Contribution Change Form

Use this form to make a change to your HSA contributions.

HSA Contribution Form

Use this form to make an HSA contribution outside of your Employer’s payroll.

HSA Custodial Agreement

All HSA participants must either accept the HSA terms on the Online Portal or sign this form and return the last page to EMPOWER.

HSA Enrollment Form

This is an enrollment form that you may distribute to your employees.

HSA Transfer Form

Form to transfer the balance from another account to the participant’s current EMPOWER HSA account.

Employer Forms

Name

Description

English

Spanish

Autopay Enrollment Form

Use this form to auto pay your EMPOWER invoices.

Banking Setup Form

Use this form to set up your Employer bank account with EMPOWER.

Nondiscrimination Questionnaire

Form for Employers to submit information for nondiscrimination testing.

Enrollment Methods

Name

Description

English

Spanish

Enrollment Spreadsheet

Use this link to download the enrollment spreadsheet to send you enrollments to EMPOWER.

EMPOWERConnect

EMPOWERConnect is an optional service that automatically integrates with your HRIS or Payroll system.

Instructional Guides

Participant Instructional Guides

Name

Description

English

Spanish

HSA Welcome Guide (PDF)

PDF guide that details the HSA Plan for new participants.

Coming Soon

HSA Welcome Guide (Online)

Comprehensive guide to using the EMPOWER HSA.

Coming Soon

Participant Portal Quick Start Guide

Learn how to use the Online Portal.

Coming Soon

Employer Instructional Guides

Name

Description

English

Spanish

Employer Welcome Guides

Guides are available that explain how to administer your EMPOWER Plan.

You will receive guides when setting up a new plan and during open-enrollment. Ask your Account Administrator for additional information.

Employer Portal Quick Start Guide

Use this guide to learn how to use the Employer Online Portal.

Additional Resources

Participant Resources

Name

Description

English

Spanish

Eligible Items

List of eligible items for all Plans.

Coming Soon

HSA Investment Options

List of HSA Investment Options

EMPOWER Participant
Mobile App Download

If you have an FSA, HRA, or HSA with EMPOWER, we encourage you to
download the Mobile App to manage your benefits on the go!
Apple iOS
Google Android

EMPOWER LOGIN

I am a Participant
Click the above link if you are a participant who has an FSA, HSA, or HRA with EMPOWER.
I am an Employer
Click the above link if you are an Employer or Consultant.

Download Forms

Click one of the links below to view the available forms.

I am a Participant
Click the above link if you are a participant who has an FSA, HSA, or HRA with EMPOWER.
I am an Employer
Click the above link if you are an Employer or Consultant.