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SelectAccount Production 2

CareFirst Printable Forms

This page contains printable forms that you can use to manage your account.

Forms List

File NameDescription
CareFirst ACH Dispute Form.pdfReview for fraud to determine if money goes back to member
CareFirst Appeal Form.pdfUsed to submit an appeal on a denial or partial claim denial
CareFirst Auth for Direct Deposit.pdfUsed by member to authorize and add/change bank account for claim reimbursement direct deposit
CareFirst Daycare Expense Reimbursement Claim Form.pdfForm that can be used to submit dependent care claims.
CareFirst Electronic Wire Transfer Form.pdfUsed by group to wire or transfer funds to Further for claims reimbursement, administrative fees, HAS/VEBA contributions or HAS/VEBA transfer from another group
CareFirst HSA Contribution Form.pdfUsed by member to request how HSA contribution will be made via check or electronic fund transfer
CareFirst HSA Recoupment form.pdfUsed by group to request recoup on contributions for various reasons e.g., contributions exceeded regulatory limits
CareFirst Letter of Medical Necessity.pdfUsed by member to identify if a potentally eligible claim can be paid
CareFirst Reclassification of HSA Funds Form.pdfWhen  a member over contributes to their HSA and has already withdrawn the funds we have to reclassify the withdrawal for tax reporting purposes.  Claims Team will reprocess an HSA claim that has already been paid out – change the withdrawal type.
CareFirst Reimbursement Return Form.pdfUsed by member to return reimbursement when selectaccount has overpaid or debit card purchase is returned. this form is used when a payment needs to be put back into the account.
Electronic Deduction and Contribution Template Carefirst.xlsxThis document provides file upload specifications for uploading HSA contribution information for members.
HRA and HIA CareFirst Medical Expense Claim Form X22030.pdfForm used for eligible expenses incurred by members or their eligible dependents for an HRA or HIA account.

 

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