Important Information About Procedures for Opening A New Account:
To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.
Eligibility Requirements for a Health Savings Account:
This enrollment form is to open a Health Savings Account that is used to accumulate assets for the payments of qualified healthcare expenses. Your health savings account is your financial asset even if you change employers or health plans.
To be eligible to open an HSA you must meet the following requirements:
- If you're currently participating in a general-purpose medical FSA, you must have a zero balance on 12-31/11 in order to be HSA-eligible on January 1st 2012. This means the claims must be incurred and filed in time to be reimbursed with the last FSA check process of the year that will occur on 12/31/2011.
- You must be covered by an HSA-qualified high-deductible health plan "HDHP" and must not be covered by other health insurance that is not an HDHP. Certain types of insurance are not considered "health insurance" and will not jeopardize an individual's eligibility of an HSA. Automobile, dental, vision, disability and long-term care insurance are allowed. You may also have coverage for a specific disease or illness as long as it pays a specific dollar amount when the policy is triggered. Wellness programs offered by employers are also permitted if they do not pay significant medical benefits.
- As long as you are covered under an HDHP policy, you can be eligible for an HSA (assuming all other eligible requirements are met). You may still be eligible for an HSA even if the policy is in your spouse's name.
- You cannot be covered by another health plan, including Medicare.
- You cannot have an HSA if a spouse's FSA or HRA can pay for any medical expenses before the HDHP deductible is met.
- You cannot be claimed as a dependent on another individual's tax return.
American Health Value does not provide medical or tax advice. Contents should not in any case replace professional medical or tax advice. If you have questions relating to a medical condition please consult a qualified healthcare professional. All tax references are on the Federal level. State taxes may vary. Please consult your tax advisor.
Acceptance of Terms:
By entering my initials I understand that ANNUAL FEES are NON-REFUNDABLE and I apply, and the institution by its signature accepts my application to establish a Health Savings Account pursuant to the terms of the Health Savings Account Agreement and Disclosure Statement (available at www.healthequity.com), which is incorporated into this application by reference.
I authorize the HSA custodian to provide American Health Value all data necessary to maintain the account. I further authorize American Health Value to access the information in my HSA to provide customer support to me. I hereby request the HSA custodian to make my account information available to American Health Value.
I understand the American Health Value administrative fee will automatically be deducted from my Health Savings Account on an annual basis.
The account holder is responsible for the establishment and maintenance of this account pursuant to Federal guidelines. Further, it is the account holder's responsibility to notify American Health Value in the future if the account holder's health insurance policy changes to continually verify ongoing HSA eligibility. American Health Value is here to assist the account holder in accomplishing this.
Health Savings Account Trust Agreement:
Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (TIN) (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding under Internal Revenue Service (IRS) regulations, or (b) I have not been notified by the Internal Revenue Service that I am subject to backup withholding as a result of failure to report all interest or dividends, or (c) the Internal Revenue Service has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. person (including a U.S. resident alien).
CERTIFICATION INSTRUCTIONS – You must cross out item 2 above if you have been notified by the Internal Revenue Service that you are currently subject to backup withholding because of underreporting interest or dividends on your tax return.
THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT OTHER THAN THE CERTIFICATION REQUIRED TO AVOID BACKUP WITHOLDING.