Health Spending Account Forms

Please Note: An HSA is a negotiated agreement between an employer and a specific employee group. Not all school jurisdictions have one. If you are unsure whether or not you have an HSA, contact your employer.

Select the form you need from the list below:

Expense Tracker Form

Before submitting a health-related expense to your Health Spending Account (HSA) make sure every other potential payer (provincial health care and/or group health and dental benefit plans) has paid their share. Submit only the amount you are actually out of pocket for.

You can use the HSA Expense Tracker to help calculate the amount to submit to your Health Spending Account when a portion of the expense is payable from another source (such as a benefit plan). Once you have done your calculations using the expense tracker, you can submit your HSA expense reimbursement request.

Download the HSA Expense Tracker Form

Expense Reimbursement Form

Note: If you have not yet completed and returned your HSA Enrollment Form to ASEBP, you must do so before ASEBP can process your HSA expense reimbursement request.

Online HSA Expense Submission - Did you know that you can submit your HSA expense reimbursement request online using My ASEBP? Help ASEBP in its efforts to go green by reducing the amount of paper that we process. Log in to My ASEBP and submit your HSA expenses now! If you have not registered for an online account yet, click here to register

Eligible Expenses - before you submit an expense to be reimbursed through your HSA, please review the information on Eligible and ineligible expenses.

If you do decide to submit your HSA expenses using a paper form, download the form using the link below. *** Read carefully the HSA Expense Reimbursement Requirements that appear on the back of the form before completing. Make a copy of the completed form for your records as the original will be retained by ASEBP. Do not submit any receipts with your form - you may be required to provide them at a later date as proof of the expenses submitted.

Download the HSA Expense Reimbursement Request Form

HSA Enrollment Form

As part of your HSA enrollment package you should have received a copy of the HSA enrollment form. ASEBP requires this form to be completed and returned to us before we can process any expense reimbursement request you submit.

Carefully read and ensure you understand the consent for the use and disclosure of your personal information and be sure to attach your current banking information to enable automatic direct deposit to your bank account. Automatic Direct Deposit is an easy and convenient way to ensure your expenses reimbursed securely to your bank.

Download the HSA Enrollment Form

Automatic Direct Deposit Form

All Health Spending Account (HSA) payments will be made by direct deposit. This is a convenient way to receive your HSA payment by having it deposited directly into your bank account.

You must complete the Automatic Direct Deposit Form and ASEBP must receive it before you will receive any payments from your HSA.

NOTE: As an added feature for HSA customers, any payment due to you for ASEBP claims submitted under your ASEBP benefit plan will also be reimbursed by direct deposit rather than by cheque.

If your banking information changes, please complete a new form and send it to ASEBP.

Download the Automatic Direct Deposit Form

For general information about Health Spending Accounts, click here.