Horizon Printable Forms
This page contains printable forms that you can use to manage your account.
Forms List
| File Name | Description |
|---|---|
| ACH Addendum Form.pdf | Addendum to the plan design guide to request different automated clearing house (ACH) accounts assigned to different group locations. ACH accounts allow for direct transfer of funds between Horizon and a group's bank account. |
| ACH Dispute Form - Horizon.pdf | This form must be filled out to dispute a transaction on an ACH account. |
| Appeal Form - Horizon.pdf | This form must be filled out if a Member wants to appeal a denied claim. |
| Authorization for Direct Deposit - Horizon.pdf | Allows members to electronically receive funds directly into their banking account instead of using a paper check. |
| Authorization For Release of Information - Horizon.pdf | This form authorizes Horizon to share certain member information to specific people |
| DCFSA-Claim-Form-Horizon.pdf | Fill out this form and submit it with your dependent care claim to receive your reimbursement. |
| Electronic Contribution Instructions Horizon.pdf | This document provides instructions and guidance for creating a contribution upload file. |
| Electronic Deduction and Contribution Template Horizon.xlsx | This document provides file upload specifications for uploading HSA contribution information for members. |
| FSA and DCFSA Enrollment Form - Horizon.pdf | Allows members to enroll in a medical FSA or dependent care FSA plan. |
| FSA Direct Plan Guide HR0921.pdf | Used by a group to design an FSA. |
| FSA Renewal Change Form-Horizon.pdf | Allows groups who automatically renew to make a change to their FSA plan. |
| FSA Transfer of Administration Addendum - Horizon.pdf | Addendum to the form allowing Horizon to take over administration of an FSA. |
| FTP Setup Form - Horizon.pdf | Allows files to be transferred via the internet |
| Group Contact Change Form - Horizon.pdf | Use this form to update the contact person for your group. |
| Group Trustee Transfer Form - Horizon.docx | Fill out when closing at BenefitWallet account and transferring funds to Further |
| HRA Direct Plan Guide 1001e.pdf | Used by a group to design an HRA. |
| HRA Renewal Change Form-Horizon.pdf | Allows groups who automatically renew to make a change to their HRA plan. |
| HRA Transfer of Administration Addendum - Horizon.pdf | Addendum t othe form allowing Horizon to take over administration of an HRA. |
| HSA and MSA Rollover Certification Form - Horizon.pdf | This form is for rolling over HSA funds and MSA funds. |
| HSA Beneficiary Designation Form - Horizon.pdf | This form allows members to change or add to the beneficiaries of their HSA. |
| HSA Contribution Form - Horizon.pdf | This form allows members to create either a one-time or recurring contribution to their HSA from a traditional checking or savings account. |
| HSA Contribution Recoupment Form - Horizon .pdf | Form required for an employer to pull funds back from a member’s HSA due to overcontribution or similar error. |
| HSA Direct Plan Guide HR0921.pdf | Used by a group to design an HSA. |
| HSA Group Contribution Submission Form - Horizon.pdf | Use this form to submit a group HSA contribution from employees and/or an employer. |
| HSA Investment Account Transaction Form - Horizon.pdf | When there are enough funds in an HSA to create an investment account, use this form to open the investment account. |
| HSA Investment Election Form - Horizon.pdf | Use this form to choose or make changes to HSA investment elections. |
| HSA Reclassification of Funds Form - Horizon.pdf | Use this form to reclassify an HSA distribution with an incorrect service type. |
| HSA Transfer Request Form - Horizon.pdf | Use this form to transfer HSA funds from another administrator to Horizon. |
| HSA Withdrawal Request Form - Horizon.pdf | Use this form to withdrawal funds from an HSA. |
| Letter of Medical Necessity - Horizon.pdf | This form must be filled out by a member and doctor for some purchases to be eligible for reimbursement. |
| Limitied Purpose FSA Addendum-Horizon.pdf | Addendum to the plan design guide to allow a group to add a limited-purpose FSA plan. |
| Medical Expense Reimbursement Claim Form - Horizon.pdf | Submit this form to file a reimbursement claim. |
| Non-Discrimination Testing Request Form - Horizon.pdf | Complete this form to allow us to administer testing to ensure your plans are compliant. |
| One-Time IRA to HSA Rollover Form - Horizon.pdf | Use this form to rollover funds from an IRA into an HSA. |
| Online Enrollment File Layout - Horizon.docx | This 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. |
| Qualifying Event Notification Form - Horizon.pdf | Use this form when a change needs to be made to a member's plan outside of open enrollment because of a qualifying event. |
| Reimbursement Return Form - Horizon.pdf | Use this form if a reimbursement must be returned to Horizon. |
| Secure File Transfer Info Agreement Form.pdf | This form must be filled out before a secure file transfer can take place. |