# Health Savings Account (HSA) Request Form

Note: As the employee you are responsible to setup your own HSA bank account prior to submitting this request to HR/Accounting. Reach out with questions. <hr@scswiderski.com>

This benefit can be used with Anthem - Option 1B and Option 1C only.

# HSA Request Form

### Health Savings Accounts (HSA) 2026 Form

Please print this document or reach out to Human Resources. Thank you!

[![Health Savings Account 2026 Form&#95;1.jpg](https://benefits.scswiderski.net/uploads/images/gallery/2025-11/scaled-1680-/health-savings-account-2026-form-1.jpg)](https://benefits.scswiderski.net/uploads/images/gallery/2025-11/health-savings-account-2026-form-1.jpg)