Printable Forms
This page contains forms that you can use for managing your group.
Overview
Did you know many group administration tasks can be performed in the Group Portal with less processing time and more convenience than a paper form? You can read about the Group Portal here.
For spreadsheets to add or update member information to your plans, visit Group Enrollment Instructions and Templates.
Forms List
| File Name | Description |
|---|---|
| ACH ADDENDUM.pdf | If you want to have different ACH accounts assigned to different Further locations, fill out this form and include it with your Plan Design Guide. |
| ADOPTION ASSISTANCE PROGRAMACCOUNT ENROLLMENT FORM.pdf | Fill out this form to enroll in the Adoption Assistance Program (AAP). |
| ADOPTION ASSISTANCE REIMBURSEMENT CLAIM FORM.pdf | This form is required in order to submit a reimbursement claim from your AAP. |
| APPEAL FORM.pdf | Form required to file an appeal of a denied claim |
| AUTHORIZATION FOR DIRECT DEPOSIT.pdf | Form that can be used to authorize us to deposit claim reimbursements directly into your bank account. This step is faster if done on the member portal. |
| AUTOMATED GROUP CLEARING HOUSE (ACH) ONLINE AUTHORIZATION AGREEMENT.pdf | Form required to authorize an administrator to withdraw funds from the employer’s bank account for claim payments, fees or contributions. |
| Autorización para depósito directo.pdf | Spanish form that can be used to authorize Further to deposit claim reimbursements directly into your bank account. |
| Board of Pensions FSA PDG.pdf | Employer/Group Form required to set up Board of Pensions FSA. |
| CUENTA DE AHORROS PARA LA SALUD SOLICITUD DE RETIRO.pdf | Spanish form used to request a withdrawal from the HSA. This step is faster if completed on the member portal. |
| DAYCARE EXPENSE REIMBURSEMENT CLAIM FORM.pdf | Form that can be used to submit dependent care claims. |
| DCAP Essential Guide.pdf | Click into this form to find out how dependent care FSA works. |
| Debit Card Request Form F9240 (1).pdf | Form that can be used to elect or add dependent debit cards. This step is faster if done on the member portal. |
| Dental Crossover Election Form.pdf | Form that can be used to elect the dental crossover option. This step is faster if done on the member portal. |
| DISBAND NOTICE.pdf | The following information is required to disband your group or product. This information will ensure that claims are processed correctly and will provide you with the information your employees or new administrator will need going forward. It also identifies what steps you need to take and what you can expect from Further. |
| Electronic Deduction and Contribution Template.xlsx | Fill out this spreadsheet when you want to upload deduction and contribution information for employees. |
| Electronic-Deduction-and-Contribution-Instructions.pdf | **This document provides instructions for filling in the Electronic Deduction and Contribution spreadsheet. |
| Employer Enrollment Form Board of Pensions HSA.pdf | Employer/Group Form required to set up Board of Pensions HSA. |
| Employer Enrollment Form Board of Pensions Premium Only Plan.pdf | Employer/Group Form required to set up Board of Pensions POP. |
| Enrollment Form Medical FSA and DCAP.pdf | Form required to enroll in the Flexible Spending Account/Dependent Care Spending Account. This step is faster if done in the Group Portal. |
| FORMULARIO DE ELECCIÓN DE TRASPASO DE RECLAMOS.pdf | Spanish form that can be used to elect medical crossover. |
| FORMULARIO DE INSCRIPCIÓN EN LA CUENTA FLEXIBLE DE GASTOS.pdf | Spanish form that can be used to enroll a member in an FSA. This step is faster if done on the online group service center. |
| FORMULARIO DE RECLAMODE LA CUENTA DE REEMBOLSODE GASTOS MÉDICOS.pdf | Spanish translation version of the form used to submit your claims and expenses to the following medical spending account types: HSA, HRA, and medical FSA. For faster service, we recommend submitting expenses using the member portal. |
| FSA TRANSFER OFADMINISTRATION ADDENDUM.pdf | By completing this form, you are selecting Further as your FSA plan administrator and authorizing Further to assume all the duties of the prior FSA plan administrator as outlined in this document. |
| Futher Online Enrollment File Layout.docx | This document provides guidance for creating an eligibility file, which provides identifying information and benefit eligibility for each employee who will have the option to enroll in our online solution. |
| Group Plan Change Form.pdf | Use this form to indicate changes for your plan for the upcoming year. |
| Group Contact Change Form.pdf | Form required to make changes to the employer’s address, group contact, agency or agent affiliation. |
| HEALTH PLAN DEDUCTIBLE TAX LIMIT VERIFICATION FORM.pdf | Use this form to verify your health plan's deductible for the plan year.x21461 |
| HEALTH REIMBURSEMENT ARRANGEMENT(HRA) ENROLLMENT FORM.pdf | Form required for HRA member enrollment if enrollment is not submitted by your health plan administrator. |
| HEALTH SAVINGS ACCOUNT CLOSE REQUEST.pdf | This form helps members close an HSA. |
| HEALTH SAVINGS ACCOUNT CONTRIBUTION FORM.pdf | Form that can be used to make a single contribution or to set up monthly electronic contributions. This step is faster if done on the member portal. |
| HEALTH SAVINGS ACCOUNT CONTRIBUTION RECOUPMENT FORM.pdf | Form required for an employer to pull funds back from a member’s HSA due to overcontribution or similar error. |
| HEALTH SAVINGS ACCOUNT ROLLOVER CERTIFICATION.pdf | Form required when a member is sending a check from a previous HSA. |
| HEALTH SAVINGS ACCOUNT TRANSFER REQUEST.pdf | Form required to request funds be transferred from another HSA administrator. |
| HRA ADD DEPENDENT FORM.pdf | Form used to collect active health plan dependents. |
| HRA TRANSFER OFADMINISTRATION ADDENDUM.pdf | By completing this form, you are selecting Further as your HRA plan administrator and authorizing Further to assume all the duties of the prior HRA plan administrator as outlined in this document |
| HSA - NOTICE OF OTHER ADMINISTRATOR.pdf | Form completed by an employer who has employees with an HSA through another administrator but have an FSA with Further. |
| HSA BENEFICIARY DESIGNATION FORM.pdf | Form required to designate, change or remove HSA beneficiaries. This step is faster if done on the member portal. |
| HSA Contribution Check Submission Form.pdf | Form that is used by a group when submitting a HSA contribution by check. |
| HSA Distribution Reclassification Form.pdf | Complete this form to reclassify member HSA distributions that were reimbursed with the incorrect service type. |
| HSA Essential Guide.pdf | This guide gives essential information on Health Savings Accounts and how HSA's can help you. |
| HSA Fact Sheet (2024 Limits).pdf | FAQ sheet for your most common questions about FSA's. |
| HSA Flyer English (2024 Limits).pdf | Health Savings Account flyer. |
| HSA Flyer Spanish (2024 Limits).pdf | Folleto HSA en español. |
| HSA OE Worksheet (2024 Limits).pdf | Health Savings Account Worksheet. |
| HSA Withdrawal Request.pdf | Form used to request a withdrawal from the HSA. This step is faster if done on the member portal. |
| LETTER OF MEDICAL NECESSITY (LOMN) .pdf | Form used when proof of medical necessity is required to reimburse an expense. |
| LOCATION ADDENDUM.pdf | Form required to set up multiple locations. |
| MEDICAL CROSSOVER ELECTION FORM.pdf | Form that can be used to elect the medical crossover option. This step is fastest if done on the member portal. |
| Medical Expense Reimbursement Form.pdf | Form used to submit your claims and expenses to the following medical spending account types: HRA, and medical FSA. For faster service, we recommend submitting expenses using the member portal. |
| Medical Savings Account vs. Health Savings Accounts.pdf | Review the benefits of converting your MSA to an HSA. |
| Member Requested Authorization for Release of Information.pdf | Form required to authorize other parties to access your account information. This step is faster if done on the member portal. |
| ONE TIME IRA TO HSA ROLLOVER REQUEST.pdf | Form required to rollover funds from an IRA to an HSA. |
| Opción pagar al proveedor Para el reembolso de gastos de atención médica.pdf | Spanish form that can be used to authorize the pay-the-provider crossover option. |
| ORTHODONTIA WORKSHEET.pdf | This worksheet provides guidance in determining the amount of orthodontia expenses that can be claimed during the upcoming plan year under a medical expense flexible spending account. |
| PREMIUM ONLY PLAN WAIVER FORM.pdf | Form completed by an employee to waive coverage in the premium only plan. |
| PREMIUM REIMBURSEMENT ACCOUNTENROLLMENT FORM.pdf | Form required to enroll in the premium reimbursement plan. |
| QUALIFYING EVENT NOTIFICATION FORM.pdf | Form required to request enrollment election changes due to an employee qualifying event. |
| Reimbursement Return Form.pdf | Form required to return overpaid funds to a spending account. |
| Secure File Transfer Information and Agreement Form.pdf | Secure File Transfer (SFT) form needed to set up your group's payroll information. |
| Solicitud de Tarjeta de Débito.pdf | Spanish form that can be used to elect or add dependent debit cards. |
| TAXSAVER HEALTH OPTIONS PREMIUM REIMBURSEMENT ACCOUNT (PRA) CLAIM FORM.pdf | Form that can be used to submit insurance reimbursement claims. This step is fastest if done on the member portal. |