Transcription of 2018 HSA Certification Form - University of Rochester
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2018 HSA Certification Form - University of Rochester
Employee ID (Required) 1 | P a g e Please return completed forms to: Office of Total Rewards, 60 Corporate Woods, Suite 310, Box 270453, Rochester , NY 14627; Fax: 585-272-0227 or Email: HSA Certification FormHealth Savings Account (HSA) Eligibility Criteria To determine your ability to enroll in a Health Savings Account per the IRS Guidelines, you will need to meet ALL therequirements below. You must elect coverage under the University s YOUR HSA-Eligible Plan for 2018. You cannot be covered by any other health plan (including spousal health insurance), except what the IRSpermits. You cannot elect nor be covered by another person s Health Care Flexible Spending Account orHealth Reimbursement Arrangement for 2018. You cannot be enrolled in any part of Medicare, Tricare, Medicaid or state health care programs.
Employee ID (Required)1 | P a g e Please return completed forms to: Benefits Office, 44 Celebration Dr., Suite 2300, P.O. Box 270453, Rochester, NY 14627; Fax:
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