How to Fill Out the WEX HSA Distribution Request and Account Closure Form

The WEX HSA Distribution Request and Account Closure Form is a one-page PDF you complete to withdraw money from your WEX Health Savings Account or close it entirely. You download it from the WEX member portal or your employer’s benefits site, fill in your identifying details, check one of eight distribution-type boxes, sign it, and send it to WEX by email, fax, or mail. A $15 fee applies if you are closing the account.¹

One thing to confirm up front: you have to use WEX’s own form. Another custodian’s distribution or closure paperwork will not work to close a WEX HSA.

What to Have Ready Before You Start

Pull the following together so you can complete the form in one sitting:

Your full legal name (first, middle initial, last) exactly as it appears on the account
Social Security Number
Employee ID Number. This is the identifier WEX uses to match you to your account. The form does not ask for a “WEX Account ID,” so check a prior benefits statement or your employer’s HR portal for the right number.
Employer name, spelled out with no abbreviations
Current mailing address and daytime phone number
The dollar amount you want distributed, or confirmation that you want the full remaining balance

If you are requesting a transfer, you also need the receiving custodian’s exact name and mailing address. Confirm that address with the receiving institution before writing it in. A wrong address can strand your funds.

If you are requesting a distribution tied to a divorce, you need a copy of the divorce decree to attach. If you are requesting a disability distribution, attach either a Social Security Administration disability award letter or a detailed physician’s statement.

Choosing a Distribution Type

Step 2 of the form lists eight boxes. You check the one that matches your reason for withdrawing:

Normal Distribution. A withdrawal for qualified medical expenses. The most common choice, and the one that keeps the money tax-free.
Excess Contribution Removal. Used when you or your employer put more into the HSA than the IRS allows. For 2026, the annual limit is $4,400 for self-only coverage and $8,750 for family coverage. You need to pull the excess out by your tax-filing deadline (typically April 15 of the following year) to avoid a 6 percent excise tax on the overage for every year it sits in the account.²
Rollover. Funds are distributed to you, and you have 60 days to deposit them into another HSA. You can only do one rollover per 12-month period.
Transfer. A trustee-to-trustee move where WEX sends the money straight to your new custodian. Fill in that custodian’s name and mailing address in the boxes on the right side of the form.
Divorce. Distributes part or all of the HSA to a former spouse under a divorce decree. Attach a copy of the decree.
Disability. Avoids the 20 percent additional tax on non-medical withdrawals. The statute ties the exception to IRC Section 72(m)(7), which generally means a medically determinable physical or mental condition expected to result in death or last continuously for at least 12 months. Attach your supporting documentation.³
Prohibited Transaction. Used when the HSA engaged in a transaction the IRS forbids, such as using HSA funds as collateral for a loan.
Mistaken Contribution. Reverses a contribution that should never have been made, for example money deposited for an employee who was never eligible for an HSA.

Pick carefully. WEX reports every distribution to the IRS on Form 1099-SA, and the code on that form corresponds to the box you checked. If you select “Normal Distribution” but used the money for something that is not a qualified medical expense, you will owe income tax plus a 20 percent additional tax on the amount.³

If You Are Closing the Account

To close the account, check the account closure box in addition to selecting a distribution type that describes where the money is going (normal distribution, rollover, or transfer, in most cases). WEX will distribute whatever cash balance remains after subtracting the closure fee.

Enter either a specific dollar amount or indicate you want the total balance. Check the figure against your most recent account statement. Pending transactions or investment liquidations can change the available cash between the moment you look and the moment WEX processes the form, and a mismatch can slow things down.

Fees

WEX charges a $15 account closure fee when you close your HSA, regardless of which distribution type you selected.¹ It is deducted from your balance before the final payout, so if your remaining balance is close to $15, confirm the exact amount available to avoid a shortfall.

A transfer to a new custodian may carry an additional transfer-out fee. Call WEX at 877-248-0510 or check the current fee schedule to confirm before submitting.

Signing and Submitting the Form

Step 3 is a signature certifying that the information you provided is true and correct. Sign and date it, then submit through one of three channels:¹

Email: forms@serviceaccount.com
Fax: 855-717-6571
Mail: PO Box 6161, Fargo, ND 58108-6161

Email and fax are faster. WEX does not spell out whether electronic signatures are accepted, so if you are emailing, the safest approach is to print, sign, scan, and send.

What Happens After You Submit

WEX reviews the form for completeness and verifies the account details. Missing fields, an unsigned form, or a distribution type that does not match the supporting documents (requesting a divorce distribution without attaching the decree, for example) will typically cause the request to be rejected and returned.

Once the form clears review, WEX either mails a physical check or initiates a direct deposit, depending on what you selected and what payment methods are on file. You can track the status through the activity log in your online WEX account dashboard.

If you chose a transfer, follow up with the receiving custodian to confirm they received the money and credited it to your new HSA. Transfers occasionally get held up when the receiving institution’s account number or address was entered incorrectly.

When You Need a Different Form

Two situations do not use this form at all.

If you are claiming an HSA as a beneficiary after the account holder’s death, WEX uses a separate Death Distribution Form. It goes to the same mailing address, fax number, and email, and a certified copy of the death certificate must accompany it.⁴

If an employer needs to reverse a mistaken employer contribution, the employer (not the employee) completes WEX’s Health Savings Account Mistaken Contributions Form. Only contributions made in the current calendar year can be reversed through that process; prior-year contributions cannot.

1
WEX. HSA Distribution Request/Account Closure Form
2
Internal Revenue Service. Revenue Procedure 2025-19
3
Office of the Law Revision Counsel. 26 U.S. Code 223 – Health Savings Accounts
4
WEX. Health Savings Account (HSA) Death Distribution Form