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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 online group service center with less processing time and more convenience than a paper form? You can read about the online group service center here

Forms List

File NameDescription
ACH Addendum.pdfIf you want to have different ACH accounts assigned to different Further locations, fill out this form and include it with your Plan Design Guide.
Authorization-for-Direct-Deposit.pdfForm 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.
Authorization-for-Release-of-Information.pdfForm required to authorize other parties to access your account information. This step is faster if done on the member portal.
DCAP-Claim-Form.pdfForm that can be used to submit dependent care claims.
DCAP-Enrollment-Form-Fillable.pdfComplete this form to enroll a member in a DCAP. This step is faster if done on the group service center.
Debit-Card-Authorization-Spanish.pdfSpanish form that can be used to elect the debit card.
Debit-Card-Request.pdfForm that can be used to elect or add dependent debit cards. This step is faster if done on the member portal.
Debit-Card-Request Spanish.pdfSpanish form that can be used to elect or add dependent debit cards.
Dental-Crossover-Election.pdfForm that can be used to elect the dental crossover option. This step is faster if done on the member portal.
Disband Notice.pdfThe 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.xlsxTemplate to be used by group administrators when uploading contributions in the Group Portal.
Electronic-Deduction-and-Contribution-Instructions.pdfInstructions for using the template that group administrators must fill out when uploading contributions in the Group Portal.
Electronic-FIle-Format-HRA.pdfThis document provides file upload specifications for electronically enrolling members in an HRA.
Electronic-File-Format-VEBA.pdfThis document provides file upload specifications for electronically enrolling members in a VEBA.
Employee HSA Contribution via Payroll Deduction Form.docxThis form can be used by employees to request a change to their payroll deductions for contributing to an HSA.
FSA Electronic Enrollment Template Instructions .pdfThis guide can help you fill out the FSA electronic enrollment spreadsheet
FSA Electronic Enrollment Template.xlsUse this spreadsheet to enroll members in an FSA or update their information
FSA Transfer of Administration Addendum.pdfBy 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.
FSA-Direct-Plan-Design-Guide.pdfForm required to set up a direct FSA.
FSA-Enrollment-Form.pdfForm required to enroll in the Flexible Spending Account/Dependent Care Spending Account. This step is faster if done on the group service center.
FSA-Plan-Design-Guide.pdfForm required to set up a new FSA plan.
Group-ACH-Agreement.pdfForm required to authorize an administrator to withdraw funds from the employer’s bank account for claim payments, fees or contributions.
Group-Contact-Change-Form.pdfForm required to make changes to the employer’s address, group contact, agency or agent affiliation.
Group-Location-Addendum.pdfForm required to set up multiple locations.
Group-Optional-Features-Change-Form.pdfForm required to make mid-year changes to the health plan information, crossover election, pay the provider option or debit card option.
HRA-Add-Dependent-Form.pdfForm used to collect active health plan dependents.
HRA-Direct-PDG.pdfForm required to set up a Direct HRA.
HRA-Electronic-Enrollment-Template.xlsxThis template can be used to upload HRA enrollment information.
HRA-Enrollment-Form.pdfForm required for HRA member enrollment if enrollment is not submitted by your health plan administrator.
HRA-Plan-Design-Guide.pdfForm required to set up your group's HRA plan that must be completed and returned 45 days before the plan's effective date.
HRA-Transfer-of-Administration-Addendum.pdfBy 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 Recoupment form.pdfForm required for an employer to pull funds back from a member’s HSA due to overcontribution or similar error.
HSA-Application.pdfHSA application that can be completed by either group or individual members. This step is faster if done on our website.
HSA-Beneficiary-Designation-Form.pdfForm required to designate, change or remove HSA beneficiaries. This step is faster if done on the member portal.
HSA-Contribution-Form.pdfForm 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.
HSA-Direct-Plan-Design-Guide.pdfForm required to set up a Direct HSA.
HSA-Distribution-Reclassification-Form.pdfComplete this form to reclassify member HSA distributions that were reimbursed with the incorrect service type.
HSA-Employer-Contribution-Form.pdfForm that is used by a group when submitting a HSA contribution by check.
HSA-Notice-of-Other-Administrator.pdfForm completed by an employer who has employees with an HSA through another administrator but have an FSA with Further.
HSA-Plan-Design-Guide.pdfForm required to set up an HSA.
HSA-Rollover-Certification.pdfForm required when a member is sending a check from a previous HSA.
HSA-Transfer-Form.pdfForm required to request funds be transferred from another HSA administrator.
HSA-Withdrawal-Request.pdfForm used to request a withdrawal from the HSA. This step is faster if done on the member portal.
IRA-Rollover-Request.pdfForm required to rollover funds from an IRA to an HSA.
Letter-of-Medical-Necessity.pdf Form used when proof of medical necessity is required to reimburse an expense.
Medical-Crossover-Election.pdfForm that can be used to elect the medical crossover option. This step is fastest if done on the member portal.
Medical-Expense-Claim-Form.pdfForm used to submit your claims and expenses to the following medical spending account types: VEBA, HSA, HRA, and medical FSA. For faster service, we recommend submitting expenses using the member portal.
Medical-Expense-Reimbursement-Form.pdfForm used to submit your claims and expenses to the following medical spending account types: VEBA, HSA, HRA, and medical FSA. For faster service, we recommend submitting expenses using the member portal.
Option-Features-Election-Spanish.pdfSpanish form that can be used to elect medical crossover.
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.
POP-Plan-Design-Guide.pdfForm required to set up an insurance reimbursement account.
PRA-Taxsaver-Claim-Form.pdfForm that can be used to submit insurance reimbursement claims. This step is fastest if done on the member portal.
Premium-Only-Plan-Waiver-Form.pdfForm completed by an employee to waive coverage in the premium only plan.
Premium-Reimbursement-Account-Enrollment-Form.pdfForm required to enroll in the premium reimbursement plan.
Qualifying-Event-Notification-Form.pdfForm required to request enrollment election changes due to an employee qualifying event.
Reimbursement-Return-Form.pdfForm required to return overpaid funds to a spending account.
Rollover-Certification.pdfForm required when a member is sending a check from a previous HSA.
SA-Appeal.pdfForm required to file an appeal of a denied claim.
SFT Information and Agreement.pdfSecure File Transfer (SFT) form needed to set up your group's payroll information.
Spanish FSA Enrollment Form.pdfSpanish form that can be used to enroll a member in an FSA. This step is faster if done on the online group service center.
Spanish-Authorization-for-Direct-Deposit.pdfSpanish form that can be used to authorize Further to deposit claim reimbursements directly into your bank account.
Spanish-DCAP-Claim-Form.pdfSpanish language version of the form that can be used to submit dependent care claims.
Spanish-DCAP-Enrollment-Form-Fillable.pdfSpanish language version of the form to enroll a member in a DCAP. This step is faster if done on the group service center.
Spanish-Debit-Card-Request.pdfSpanish form that can be used to elect or add dependent debit cards.
Spanish-FSA-Enrollment-Form.pdfSpanish language form required to enroll in the Flexible Spending Account/Dependent Care Spending Account. This step is faster if done on the group service center.
Spanish-HSA Beneficiary Designation Form.pdfSpanish language form required to designate, change or remove HSA beneficiaries. This step is faster if done on the member portal.
Spanish-HSA Contribution Form.pdfSpanish language 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.
Spanish-HSA Direct PDG.pdfSpanish language form required to set up a Direct HSA.
Spanish-HSA Employer Contribution Form.pdfSpanish language form that is used by a group when submitting a HSA contribution by check.
Spanish-HSA Rollover Certification.pdfSpanish language form required when a member is sending a check from a previous HSA.
Spanish-HSA Transfer Form.pdfSpanish language form required to request funds be transferred from another HSA administrator.
Spanish-HSA-Application.pdfSpanish HSA application for employer-sponsored HSA plans.
Spanish-HSA-Withdrawal-Form.pdfForm used to request a withdrawal from the HSA. This step is faster if completed on the member portal.
Spanish-Letter of Medical Necessity.pdfSpanish translation version of the form used when proof of medical necessity is required to reimburse an expense.
Spanish-Medical Expense Reimbursement Form.pdfSpanish translation version of the form used to submit your claims and expenses to the following medical spending account types: VEBA, HSA, HRA, and medical FSA. For faster service, we recommend submitting expenses using the member portal.
Spanish-Option-Features-Election.pdfSpanish form that can be used to elect medical crossover.
Spanish-Pay-the-Provider-Crossover-Election.pdfOpcion Pagar al Proveedor: Spanish form that can be used to authorize the pay-the-provider crossover option.
Spanish-Qualifying Event Notification.pdfSpanish translation version of the form required to request enrollment election changes due to an employee qualifying event.
Spanish-Reimbursement Return Form.pdfSpanish translation version of the form required to return overpaid funds to a spending account.
TaxSaver-Health-Options-Enrollment-Form.pdfForm required to enroll in the TaxSaver plan.
TRA Enrollment Form.pdfForm for enrolling a member in a TRA. This step is faster if done on the online group service center.
Transfer-Request.pdfForm required to request funds be transferred from another HSA administrator.
TRA-Payroll-Deduction-Report-File-Sample.xlsxSample file to be used for uploading payroll deductions for a TRA. This file template lets you upload TRA payroll deductions for multiple members at a time.
TRA-Plan-Design-Guide-Fillable.pdfForm required to set up a Transportation and Parking plan.
VEBA Attestation of Waiver of Benefits.pdfIf a VEBA beneficiary would like to waive their rights to an account and designate a new beneficiary or revert the account back to the VEBA trust, this form should be completed.
VEBA-Account-Option-Form.pdfForm that can be used to limit or prevent payments from being made from the VEBA account.
VEBA-Add-Dependent-Form.pdfForm used to collect active health plan dependents.
VEBA-Beneficiary-Designation-Form-Fillable.pdfForm required to designate a VEBA beneficiary.
VEBA-Contribution-Form.pdfForm required for submission of VEBA contributions by check.
VEBA-Direct-Plan-Design-Guide.pdfForm required to set up a Direct VEBA.
VEBA-Electronic-Enrollment-Template.xlsxTemplate to be used with the Electronic Enrollment File - VEBA specifications.
VEBA-Enrollment-Form.pdfForm required to enroll employees in the VEBA.
Wellness-HRA-Plan-Design-Guide.pdfForm required to set up a wellness HRA.