Use the Employee Contribution Correction Request form (ECCR form) to request a correction to a contribution to a Health Savings Account (HSA) owned by an employee (Account Holder) made in error by the employer.
The ECCR form can always be found in the employer portal by going to Resources > Resource Documents, then clicking the form’s hyperlink.
Note: Incomplete forms will not be processed. In such cases, we will attempt to contact you via email or phone to advise you that the form was missing information.
Submit the completed form in Support Center through the Employer Portal or contact employerservices@healthequity.com. Or reach out to your Service Delivery Manager.
Please use the following directions to complete the form.
All fields are required.
Employer Information
All fields must be filled out so HealthEquity can contact the employer if there are any questions or issues:
Field | Instructions |
Company | Enter the full company name as it appears on record at HealthEquity. |
Contact | Enter the full name of the authorized HealthEquity contact filling out the form. |
Phone | Enter a company or contact phone number including area code in (000)000-0000 format. Do not enter a Social Security Number (SSN) in this field. |
Account holder and correction information
All fields must be filled out correctly so HealthEquity can perform the correction on the right account.
Field | Instructions |
Last 4 digits of the SSN or HealthEquity ID number | Enter the LAST 4 digits of the employee’s SSN OR enter their entire HealthEquity Member ID - NOT their Employee ID. |
Last name | As it appears on record at HealthEquity (in their employee listing); if there is a mismatch, HealthEquity cannot process until the member is verified. |
First name | As it appears on record at HealthEquity (in their employee listing); if there is a mismatch, HealthEquity cannot process until the member is verified. |
Middle Initial (MI) | Enter the MI as it appears on record at HealthEquity (in their employee listing); if there is a mismatch, HealthEquity cannot process until the member is verified. |
Employer contribution amount requested to be returned | Enter the amount of funds to be returned from the funds contributed by the Employer into the member’s HSA. |
Account Holder contribution amount requested to be returned | Enter the amount of funds to be returned from the funds deducted from the member’s paycheck and deposited into their HSA by the employer. Funds sent via Direct Deposit will always be considered employee contributions. |
Tax year | Enter the tax year the funds are intended to be pulled from. |
Reason for correction
An option MUST be selected to process the form. Only select ONE option.
Option | Signature requirement |
1. Administrative or process error (with situations acknowledged by the Internal Revenue Service (IRS) and clear documentary evidence). | No member signature is needed; however, the employer is still responsible for advising the member account holder that funds will be removed from their account and why. |
2. Account Holder never eligible (IRS Notice 2008-59 Q/A 23). | A valid signature and date from the member account holder and the employer contact representative is required for processing. |
3. Employer contributed amount that exceeds the maximum annual contribution allowed (IRS Notice 2008-59 Q/A 24). | A valid signature and date from the member account holder and the employer contact representative is required for processing. |
Processing options and notes
Select only one option. An option MUST be selected to process.
Please note that fund corrections made using ECCR form cannot be returned directly to the member and will be returned to the employer. If funds returned need to go to the member, the employer will need to reimburse the member themselves.
Option | Details |
Option 1 – Credit Invoice | Credits will be issued to the employer account. |
Option 2 – Check | Checks will be mailed to the employer address on file. |
Option 3 – Send to verified employer Electronic Fund Transfer (EFT) account on file | The last 4 digits of the employer account number are required.
If the last 4 digits of the employer account number aren’t indicated and there’s more than one EFT on file, HealthEquity cannot process the correction until a specific account is confirmed. |
Option 4 – One-time (EFT). | Form must be accompanied by a copy of a voided or actual check.
We strongly discourage using this option, as any EFT information input into the system to process a correction will remain on file.
It is best for the employer to set up their EFT account beforehand if that is how they wish to have the funds returned to them. |
Account holder authorization
This section is for the member/employee signature if required by selecting Reason for Correction options 2 or 3. If option 1 was selected, this section can remain blank. We do NOT accept employer signatures in this section. This section contains the member agreement only.
Field | Description |
Employee Signature | Must be wet, cursive-typed, or verified via Docusign or similar. |
Date | Must be dated within 90 days of the date of processing and cannot be future dated. |
Employer authorization (2nd page) It is strongly encouraged that the employer read the employer agreement on this page of the form. An employer rep MUST sign and date this 2nd page of the form to process.
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Employer authorization (2nd page)
It is strongly encouraged that the employer read the employer agreement on this page of the form. An employer rep MUST sign and date this 2nd page of the form to process.
Field | Description |
Employer Signature | Must be wet, cursive-typed, or verified via Docusign or similar. |
Date | Must be dated within 90 days of the date of processing and cannot be future dated. |