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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
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. This step is faster if done on the member portal.
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.
Dental-Crossover-Election.pdfForm that can be used to elect the dental crossover option. This step is faster if done on the member 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.
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 an FSA.
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 an HRA.
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-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.
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.
Pay-the-Provider-Crossover-Election-Spanish.pdfOpcion Pagar al Proveedor: Spanish form that can be used to authorize the pay-the-provider crossover option.
POP-PRA-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.
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-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.
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-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.
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