CareFirst Printable Forms
This page contains printable forms that you can use to manage your account.
Forms List
| File Name | Description |
|---|---|
| CareFirst AAP Reimbursement Claim Form.pdf | This form is required for claiming a reimbursement from your adoption assistance plan. |
| CareFirst BlueFund HSA Payroll Deduction Election Form.pdf | An employee uses this form to authorize payroll contributions to their HSA. |
| CareFirst Electronic Contributions Instructions.pdf | Guide and FAQs to create your electronic contribution spreadsheet. |
| CareFirst FSA Enrollment Form.pdf | Use this form to enroll in an FSA plan. |
| CareFirst HRA Plan Design Guide.pdf | Complete to enroll a group in an HRA plan |
| CareFirst HSA Plan Design Guide.pdf | Complete to enroll a group in an HSA plan |
| CareFirst HSA Transfer Form and Instructions.pdf | Complete the form included here to transfer funds from another account into a CareFirst HSA. |
| CareFirst ACH Dispute Form.pdf | Review for fraud to determine if money goes back to member |
| CareFirst Appeal Form.pdf | Used to submit an appeal on a denial or partial claim denial |
| CareFirst Auth for Direct Deposit.pdf | Used by member to authorize and add/change bank account for claim reimbursement direct deposit |
| CareFirst Daycare Expense Reimbursement Claim Form.pdf | Form that can be used to submit dependent care claims. |
| CareFirst Electronic Wire Transfer Form.pdf | Used 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.pdf | Used by member to request how HSA contribution will be made via check or electronic fund transfer |
| CareFirst HSA Recoupment form.pdf | Used by group to request recoup on contributions for various reasons e.g., contributions exceeded regulatory limits |
| CareFirst Letter of Medical Necessity.pdf | Used by member to identify if a potentally eligible claim can be paid |
| CareFirst POP Plan Design Guide.pdf | Complete to enroll a group in a POP plan |
| CareFirst Reclassification of HSA Funds Form.pdf | When a member over contributes to their HSA and has already withdrawn the funds we have to reclassify the withdrawal for tax reporting purposes.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.pdf | Used 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. |
| CareFirst-POP-Waiver-Form.pdf | Members complete this form if they don't want to participate in CareFirst's Premium Only Plan. |
| Electronic Deduction and Contribution Template Carefirst.xlsx | This document provides file upload specifications for uploading HSA contribution information for members. |
| HRA and HIA CareFirst Medical Expense Claim Form X22030.pdf | Form used for eligible expenses incurred by members or their eligible dependents for an HRA or HIA account. |