New Page 1
HomeAdmin ServicesHSA InfoOpen an HSABusiness SolutionsAccount HoldersBrokers

Guidelines to Open an HSA

  1. Graphic SportsDownload the “HSA Application and Custodial Agreement ” form.
  2. Fill out the “Account Holder Information” section including your name and contact information.
  3. If you are applying for an HSA through your work place, please fill out the “Employer Information” section.
  4. Complete the “Eligibility Information” section to determine your HSA eligibility.
  5. Fill out the “High Deductible Health Plan” (HDHP) section. To be eligible for an HSA, you must be covered by a high deductible health plan.
  6. Fill out the “Primary Beneficiary” and “Contingent Beneficiary” sections. This person will inherit your HSA upon your death. If no one is listed, the account will transfer to your estate.
  7. Fill out the “Electronic Funds Transfer ” section to authorize transfers between your personal bank account and your HSA.
  8. Sign, date and send the HSA Application and Beneficiary Designation form along with your check for $88 ($63 annual administration fee including smart debit card plus an initial $25 one time only, administration set up fee) to Kereon HSA, Inc.
Forms to Submit Online or Download

What Else?

Before completing the HSA Application and Beneficiary Designation Form, carefully read the HSA Custodial Account Agreement which includes the Disclosure Statement, Terms and Conditions and the Privacy Protection Notice.


HSA Application and Custodial Agreement
Transfer Current HSA to Kereon HSA
IRA Transfer to Kereon HSA

Taking Care of You is our Number One Priority

We make it easy for you. Fill out the HSA Application and Beneficiary Designation Form, then return it to Kereon HSA via fax or mail. The fax and address are on the back of the application. Kereon HSA (your Plan Service Provider) will then forward your application to the Custodian to establish your Health Savings Account.

New Page 1

Copyright © 2005-2021 - Kereon HSA, Inc. - All rights reserved.

1161 Wayzata Blvd, #184
Wayzata, MN  55391
Phone: 952.449.3618
Fax: 952.449.3619