Getting Started with a Health Spending Account

The first step is to determine what your expected family healthcare expenses will be for the next 12 months using the form below.

Next, you need to make the necessary arrangements with your employer to redirect money to the HSA administrator from your usual pay. (This can be done monthly or as needed.)

Whenever you incur an eligible expense you simply submit the bill and it will be reimbursed within 10 days. You can also arrange direct payment to your health service provider.

Step 1: Calculate the Annual Healthcare Expenses for yourself and/or your family.

1.	Prescription Drugs		Total
	Person 1	$
	Person 2	$
	Person 3	$	Prescription Drug Subtotal
	Person 4	$
			$
2.	Professional Services (Chiropractic, Massage etc.)
	Person 1	$
	Person 2	$
	Person 3	$	Professional Service Subtotal
	Person 4	$
			$
3.	Eye Care
	Person 1	$
	Person 2	$
	Person 3	$	Eyecare Subtotal
	Person 4	$
			$
4.	Dental Care
	Person 1	$
	Person 2	$
	Person 3	$	Dental Care Subtotal
	Person 4	$
		Subtotal:	$
5.	Other Special Needs
	Person 1	$	Special Needs Subtotal
	Person 2	$
		Subtotal:	$
6.	Unique Expenses
	Orthodontics	$
	Fertility Treatments	$
	Hair Replacement	$
	Spinal Decompression	$
	MRI	$
	Laser Eye Surgery	$
	Cosmetic Procedures	$	Unique Expenses Subtotal
	Diabetic Supplies	$
			$
			$

Step 2: Once you have calculated your Annual Expense Total, calculate how much you can save with a Health Spending Account. Transfer your Annual Expense Total to calculate your savings.

Step 3: To set up a Health Spending Account, please fill in the form below and you will be contacted shortly by a representative of the Total Concept Group to confirm the specific requirements for your participation. Please fill in all requested information.

First Name:
Last Name:
Address:
City:
Province:
Postal Code:
Phone #:
E-mail Address:
Employment Status:	Please check the box that best describes your situation  I am Self employed / Sole Proprietor If your spouse or significant other is self employed or a sole proprietor, please answer the following questions.  I do not personally work for their business  I DO personally work for their business  I am the owner / shareholder of an Incorporated Canadian Small Business If you are an employee of an unrelated company, select which option best describes your situation.  I have no benefit plan  My benefit plan has shared payments and limitations on coverage  My benefit plan does not cover my family's medical expenses
Estimated Yearly Healthcare Expenses:
Are you anticipating any imminent healthcare expenses?	Yes  No
For what?:
For you or a family member?	Me Another family member please specify below):

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For more information, you can reach us at the following co-ordinates:

Total Concept Group
65 Lynngrove Ave., Toronto, ON M8X 1M7
Phone: 416-465-8226

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