HSA Account Transfer Form

This form is used to request an HSA Transfer or Rollover from a prior custodian to DataPath Administrative Services.

General Information

An account transfer, or rollover, is how money or property can be moved into a Health Savings Account (HSA) from a Medical Savings Account (MSA) or existing HSA. The Internal Revenue Code (IRC) limits how many rollovers may be taken, how quickly they must be completed, and how the Trustee or Custodian must report the transaction. By properly completing this form you are certifying to the Trustee or Custodian that you have satisfied the rules and conditions applicable to your rollover and that you are making an irrevocable election to treat the transaction as a rollover.


Timelines – Funds received from a MSA or HSA must be deposited into an HSA within 60 days after receipt. When counting the 60 days, include weekends and holidays. Generally there are no exceptions to the 60-day rule, and the IRS cannot grant extensions. ‘Receipt’ generally means the day you actually have the funds in hand. For example, the 60 days would begin on the day you pick up the check from the Trustee or Custodian or you receive the check in the mail.

Twelve-Month Restriction – You can make one rollover distribution per year from a HSA account. Twelve (12) months must elapse between the time you receive a distribution of the assets to be rolled over and the time you can receive another distribution of those same assets for rollover purposes.

To Transfer Funds to HSAToday


To Transfer Funds to Summit HSA