American Health Value

Electronic Funds Transfer Request Form

Your First Name (required):
Your Last Name (required):
Your email address (required):
Account Number (required):
Phone Number (required):
Fax Number:
Street Address (required):
City (required):
State (required):
Zip Code (required):

* Federally Qualified HSA: To have a Federally Qualified HSA, you must purchase and maintain a high-deductible insurance policy and you cannot be covered by another low-deductible insurance policy.

* Note on compliance with your health plan: This Internet site describes services and benefits of the American Health Value HSA Account, which are subject to change without notice. It is not intended to provide legal, health, or tax advice. Consult your own legal, medical, and tax counsel for guidance on issues that may be affected by your specific circumstances.

* Please note the conditions of your plan: If you intend to use the American Health Value HSA to pay your deductible or other services covered under you health care plan, we strongly recommend that you always comply with the conditions of your plan, including pre-certification requirements.