Health Savings Account Designation of Authorized Signer

Midwest Heritage provides the option for the designation of an authorized signer who can exercise certain rights with respect to the HSA. This designation of an authorized signer is applicable only to the funds held in your Midwest Heritage HSA and can be revoked or changed by you in writing at any time. To designate an authorized signer for your HSA, please fill out their information below.

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HSA Information

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Authorized Signer Information:

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Address*
For security purposes, Midwest Heritage may contact the Authorized Signer to obtain identifying information such as Social Security number.*
Regulations require that only one individual own a Health Savings Account (HSA), however, Midwest Heritage provides for the designation of an authorized signer who can exercise certain rights with respect to the HSA. This designation of an authorized signer is applicable only to the funds held in your Midwest Heritage HSA and can be revoked or changed by you in writing at any time. You authorize him/her to perform transactions on my behalf including: Request funds disbursements, such as debit card, check, ACH, transfer or by any other means; Make deposits or transfers to the HSA; Inquiries including balance, transaction, statements or any other information pertaining to the HSA; Order checks and debit cards; and Notify Midwest Heritage of any HSA-related disputes. You specifically authorize Midwest Heritage, as custodian of your HSA, to rely upon this authorization and designation until such time, if any, that Midwest Heritage receives a written revocation of this authorization and has time to act upon the revocation. You understand that you are responsible for ensuring the authorized signer reads and understands the HSA account documents and disclosures that have been provided to you. You further understand that you bear sole responsibility for any tax consequences that result from any actions taken by the authorized signer regarding your HSA. No present or future ownership or right of survivorship is given to the authorized signer by this authorization. Upon notice to Midwest Heritage of your death, this authorization terminates and rights to the funds in your HSA will be transferred to your beneficiaries. In the event you did not name a beneficiary, or your beneficiary predeceases you, your HSA balance will be transferred to your estate.*