Health Savings Account Eligibility Survey
Answer the following questions to determine your eligibility for a Health Savings Account (HSA).
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Are you currently covered by a High Deductible Health Plan (HDHP)?
*
Yes
No
Do you have any other health coverage (excluding permitted insurance such as dental, vision, disability, or long-term care)?
*
Yes
No
Not Sure
Are you enrolled in Medicare?
*
Yes
No
Can you be claimed as a dependent on someone else's tax return?
*
Yes
No
Not Sure
If you have any questions or additional information, please provide details below.
Submit Eligibility Survey
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