Interview Notes .. Carol Wheeler, age 56, is single. Carol earned wages of $48,000 and was enrolled the entire year in a high deductible health plan (HDHP) with self-only coverage. During the year, Carol contributed $3,000 to her Health Savings Account (HSA) and her cousin also contributed $1,000 to Carol's HSA account. Carol's Form W-2 shows $600 in Box 12 with code W. She has Form 5498-SA showing $4,600 in Box 2. . Carol took a distribution from her HSA to pay her unreimbursed expenses: 2 visits to a physical therapist due to a car accident $300 unreimbursed doctor bills for $700 prescription medicine $400 replacement of a crown $1,500 over the counter sinus medication $80 10 Zumba classes for $125 Carol is a U.S. citizen with a valid Social Security number 6. Form 8889, Part 1 is used to report HSA contributions made by. OA. Carol OB. Carol's employer OC. Carol's cousin OD. All the above