Health Savings Account Disclosures and Forms

Please print and mail forms to Bank of Nebraska, 7223 S 84 St, La Vista, NE 68128.  Do not email these forms.   These forms contain personal information, such as your social security number.  Email is not a secure form of communication.

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Please fill in and complete the Customer Identification Worksheet and the HSA Application.  You may download the remaining disclosures for your records. 

Please fax the Worksheet and the Application to the bank at 402-331-8570.  Do NOT email these documents.  Email is not a secure communication.

Customer Identification Worksheet

HSA Package

HSA Application

HSA Transfer Request

Electronic Funds Transfer Agreement

Funds Availability

HSA Contribution Form

HSA Debit Card Application

HSA Disclosure Statement

Privacy Disclosure

Change of Beneficiary