Get Payflex Account Closure Form

Closing your Payflex Health Savings Account (HSA) requires careful completion of the Account Closure Form. This guide provides clear, step-by-step instructions to help you fill out the form accurately and efficiently.

Follow the steps to successfully complete the payflex account closure form

1. Press the ‘Get Form’ button to access the Payflex Account Closure Form and open it for editing.
2. In Section 1, provide your personal information. Ensure you include your first name, middle initial, last name, social security number (last four digits), and your HSA account number, which can be found on your monthly statement or your online account.
3. Move to Section 2 and select the appropriate reason for closing your account. If you are the beneficiary due to the account owner's death, include a copy of the death certificate and any proof of your role as the executor or administrator of the estate. Indicate the preferred method of disbursement: via electronic funds transfer or by mailing a check.
4. Sign and date the form where indicated to authorize Payflex to close your HSA. Make sure the information you provided is complete and accurate, as this will also pertain to tax responsibilities.
5. If applicable, please provide your contact number and the relationship to the account owner if you are submitting as a named beneficiary or executor.
6. Finally, review the completed form for accuracy, save your changes, and prepare the form for submission by mailing it to PayFlex Systems USA, Inc. at the address provided at the bottom of the form.

Complete your Payflex Account Closure Form online accurately and submit it for processing.