HSA Transfer Request Form (Archive 12/30/17)

This content has been archived. It may no longer be relevant

If you currently have a Health Savings Accounts (HSA) with WageWorks / BNY Mellon and wish to transfer all of your funds directly to DataPath / HSAToday, please complete the below form and click Submit.

I understand this is completely voluntary and BNY Mellon will charge the $16 Transfer of Asset fee to my account.*  If I choose to keep my HSA account with WageWorks, I will become responsible for the monthly fees associated with my account administered by WageWorks and the custodial bank, BNY Mellon. Beginning January 1, 2017, any HSA contributions I elect through payroll and all employer contributions will go into my DataPath / HSAToday account only.
* Note: EBD will credit your account $16 to cover the BNY Mellon transfer fee.

Current Custodian:	WageWorks / BNY Mellon
WageWorks Phone/Fax:	877-924-3967
WageWorks Address:	P.O. Box 9813, Providence, RI 02940-8013
First Name:
Last Name:
SSN (numbers only):
Date of Birth:
Street Address:
City:
State (abbreviations only):
Zip (numbers only):
Phone (incl area code):
Email Address:
	By checking the box below, you agree that your Name as typed above serves as your electronic signature and is intended to authenticate this transfer and to have the same force and effect as your manual signature. By your electronic signature, you authorize DataPath, Inc. to complete this one-time account transfer.  I authorize the transfer of all my HSA assets from WageWorks / BNY Mellon to DataPath / National Advisors Trust Company, FSB.
	[wc_spacing size=”20px”]Please contact us with any questions or concerns.