Skip to main
Health Savings Account Amendment Form 2021-2022
Click to view (pdf or doc)
Plan year July 1, 2021 through June 30, 2022
Use this form at any time during the year to start, stop, increase, or decrease the amount you contribute to you HSA.
Revision date: 04/23/2021
Submit paper form to Benefits Office, 112 Scovell Hall, Lexington KY 40506-0064
Email form back to email@example.com