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Further Learning Site

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 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.
ADOPTION ASSISTANCE PROGRAM (AAP) DIRECT PLAN DESIGN GUIDE.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.
ADOPTION ASSISTANCE PROGRAMACCOUNT ENROLLMENT FORM.pdfFill out this form to enroll in the Adoption Assistance Program (AAP).
ADOPTION ASSISTANCE REIMBURSEMENT CLAIM FORM.pdfThis form is required in order to submit a reimbursement claim from your AAP.
APPEAL FORM.pdfForm required to file an appeal of a denied claim
ARKANSAS BLUE CROSS BLUE SHIELD FLEXIBLE SPENDING ACCOUNT (FSA) PLAN DESIGN GUIDE.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.
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.
AUTOMATED GROUP CLEARING HOUSE (ACH) ONLINE AUTHORIZATION AGREEMENT.pdfForm required to authorize an administrator to withdraw funds from the employer’s bank account for claim payments, fees or contributions.
Autorización para depósito directo.pdfSpanish form that can be used to authorize Further to deposit claim reimbursements directly into your bank account.
CUENTA DE AHORROS PARA LA SALUD SOLICITUD DE RETIRO.pdfSpanish form used to request a withdrawal from the HSA. This step is faster if completed on the member portal.
DAYCARE EXPENSE REIMBURSEMENT CLAIM FORM.pdfForm that can be used to submit dependent care claims.
Debit Card Request Form F9240 (1).pdfForm 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.pdfForm that can be used to elect the dental crossover option. This step is faster if done on the member portal.
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT ENROLLMENT FORM.pdfComplete this form to enroll a member in a DCFSA. This step is faster if done on the group service center.
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.xlsxFill 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.
FLEXIBLE SPENDING ACCOUNT (FSA) DIRECT PLAN DESIGN GUIDE.pdfForm required to set up a direct FSA.
FLEXIBLE SPENDING ACCOUNT (FSA) EMPLOYER ENROLLMENT FORM.pdfEmployer/Group Form required to set up Board of Pensions FSA.
FLEXIBLE SPENDING ACCOUNT (FSA) PLAN DESIGN GUIDE.pdfForm required to set up a new FSA plan.
FLEXIBLE SPENDING ACCOUNT ENROLLMENT FORM.pdfForm 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.pdfSpanish form that can be used to elect medical crossover.
FORMULARIO DE INSCRIPCIÓN EN LA CUENTA FLEXIBLE DE GASTOS.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.
FORMULARIO DE RECLAMODE LA CUENTA DE REEMBOLSODE GASTOS MÉDICOS.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.
FSA TRANSFER OFADMINISTRATION 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.
Futher Online Enrollment File Layout.docxThis 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 CONTACT CHANGE FORM.pdfForm required to make changes to the employer’s address, group contact, agency or agent affiliation.
HEALTH PLAN DEDUCTIBLE TAX LIMIT VERIFICATION FORM.pdfUse this form to verify your health plan's deductible for the plan year.x21461
HEALTH REIMBURSEMENT ARRANGEMENT (HRA) DIRECT PLAN DESIGN GUIDE.pdfForm required to set up a Direct HRA.
HEALTH REIMBURSEMENT ARRANGEMENT (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.
HEALTH REIMBURSEMENT ARRANGEMENT(HRA) ENROLLMENT FORM.pdfForm required for HRA member enrollment if enrollment is not submitted by your health plan administrator.
HEALTH SAVINGS ACCOUNT (HSA) DIRECT PLAN DESIGN GUIDE.pdfForm required to set up a Direct HSA.
HEALTH SAVINGS ACCOUNT (HSA) EMPLOYER ENROLLMENT FORM.pdfEmployer/Group Form required to set up Board of Pensions HSA.
HEALTH SAVINGS ACCOUNT (HSA) PLAN DESIGN GUIDE.pdfForm required to set up an HSA.
HEALTH SAVINGS ACCOUNT APPLICATION.pdfHSA application that can be completed by either group or individual members. This step is faster if done on our website.
HEALTH SAVINGS ACCOUNT CLOSE REQUEST.pdfThis form helps members close an HSA.
HEALTH SAVINGS ACCOUNT 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.
HEALTH SAVINGS ACCOUNT CONTRIBUTION RECOUPMENT FORM.pdfForm required for an employer to pull funds back from a member’s HSA due to overcontribution or similar error.
HEALTH SAVINGS ACCOUNT ROLLOVER CERTIFICATION.pdfForm required when a member is sending a check from a previous HSA.
HEALTH SAVINGS ACCOUNT TRANSFER REQUEST.pdfForm required to request funds be transferred from another HSA administrator.
HEALTH SAVINGS ACCOUNT WITHDRAWAL REQUEST.pdfForm used to request a withdrawal from the HSA. This step is faster if done on the member portal.
HRA ADD DEPENDENT FORM.pdfForm used to collect active health plan dependents.
HRA TRANSFER OFADMINISTRATION 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 - 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 BENEFICIARY DESIGNATION FORM.pdfForm required to designate, change or remove HSA beneficiaries. This step is faster if done on the member portal.
HSA Contribution Check Submission Form.pdfForm that is used by a group when submitting a HSA contribution by check.
LETTER OF MEDICAL NECESSITY (LOMN) .pdfForm used when proof of medical necessity is required to reimburse an expense.
LOCATION ADDENDUM.pdfForm required to set up multiple locations.
MEDICAL CROSSOVER ELECTION FORM.pdfForm that can be used to elect the medical crossover option. This step is fastest if done on the member portal.
MEDICAL EXPENSE REIMBURSEMENTACCOUNT CLAIM FORM.pdfForm used to submit your claims and expenses to the following medical spending account types: VEBA, HRA, and medical FSA. For faster service, we recommend submitting expenses using the member portal.
Member Requested 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.
ONE TIME IRA TO HSA ROLLOVER REQUEST.pdfForm required to rollover funds from an IRA to an HSA.
Opción pagar al proveedor Para el reembolso de gastos de atención médica.pdfSpanish form that can be used to authorize the pay-the-provider crossover option.
ORTHODONTIA WORKSHEET.pdfThis 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.
PLAN CHANGES FORM.pdfUse this form to indicate changes for your plan for the upcoming year.
PREMIUM ONLY PLAN WAIVER FORM.pdfForm completed by an employee to waive coverage in the premium only plan.
PREMIUM ONLY PLANPLAN DESIGN GUIDE.pdfForm required to set up an insurance reimbursement account.
PREMIUM REIMBURSEMENT ACCOUNTENROLLMENT 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.
RECLASSIFICATIONOF HSA FUNDS.pdfComplete this form to reclassify member HSA distributions that were reimbursed with the incorrect service type.
REIMBURSEMENT RETURN FORM.pdfForm required to return overpaid funds to a spending account.
Secure File Transfer Information and Agreement Form.pdfSecure File Transfer (SFT) form needed to set up your group's payroll information.
SOLICITUD DE LA HSA (CUENTA DE AHORROS DE SALUD).pdfSpanish HSA application for employer-sponsored HSA plans.
Solicitud de Tarjeta de Débito.pdfSpanish form that can be used to elect or add dependent debit cards.
TAXSAVER HEALTH OPTIONS PREMIUM REIMBURSEMENT ACCOUNT (PRA) CLAIM FORM.pdfForm that can be used to submit insurance reimbursement claims. This step is fastest if done on the member portal.
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.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 ENROLLMENT FORM.pdfForm required to enroll employees in the VEBA.
WELLNESS INCENTIVE (HRA)PLAN DESIGN GUIDE.pdfForm required to set up a wellness HRA.