ACH Wire Transfer Request: If you would like IMG to use Direct Deposit to send reimbursement for
medical claims or other reimbursable medical costs paid out by you as a member, please indicate
below by completing full details of bank and transfer information.
Name of Member: _______________________________________________________________
IMG Member ID or NSPID*: _______________________________________
Name of Account Holder (exactly as it appears on the account): ______________________________
Bank Account Number: _____________________ Routing Number: _______________________
Bank Name: _____________________ Bank Phone Number: ____________________________
Bank Address: __________________________________________________________________
*The IMG Member ID can be found on your ID card issued by IMG. The NSPID is your personal identication number
issued by AmeriCorps, you may nd this number by accessing your account on the My AmeriCorps portal.
ACH or Wire Transfer Form
I hereby authorize International Medical Group, Inc. (IMG) to electronically credit my account for the
reimbursement of eligible medical costs as allowable under the AmeriCorps VISTA health benet
program. I understand that this authorization will remain in force until revoked by me in writing.
Member Signature: _________________________________ Date:___________________________
You may submit completed form to IMG by:
Fax: (855) 851-2971
Postal Mail: IMG
P.O. Box 550
Farmington, MI 48332-0550
We are required by the Privacy Act of 1974 (5 U.S.C. 552a) to tell you what personal information we collect and how it will be used: Authorities This information is
requested pursuant to 42 U.S.C. 4955, Support services; 42 U.S.C. 12618, Authorized benefits for Corps members; and 45 CFR § 2556.320 - What benefits may a
VISTA receive during VISTA service? Purposes It is requested to manage and evaluate the health benefits programs offered to VISTA, NCCC, and FEMA Corps
Members. Routine Uses Routine uses of this information may include disclosure to (1) health care providers and insurance companies to provide care and coordinate
payment, (2) contractors to assist with providing the health care benefit, and (3) federal, state, or local agencies pursuant to lawfully authorized requests. Effects of
Nondisclosure – This request is voluntary, but not providing the information will likely affect your ability to receive your health care benefits.
*Notice on Electronic Communication and Privacy: Please submit these documents via secure means, such as encrypted email or by fax. If you choose to send
the information via unsecure email, you are solely responsible for any subsequent data breach or data loss caused by your decision. To protect your private information,
we recommend you consider using any secure or confidential/encrypted email sending options with your email service provider. You may also consider
password protecting your documents and sending the password in a separate email.
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