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 Name | Description |
|---|---|
| AAP Enrollment Form.pdf | Fill out this form to enroll in the Adoption Assistance Program (AAP). |
| AAP PDG.pdf | Use this plan design guide to set up your group's Adoption Assistance Program (AAP) |
| Access Form HSA F9123.pdf | Use this form to choose an option for your HSA access authorization. |
| ACH Addendum.pdf | If 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 Reimbursement Claim Form.pdf | This form is required in order to submit a reimbursement claim from your AAP. |
| Authorization-For-Direct-Deposit.pdf | Form 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.pdf | Form required to authorize other parties to access your account information. This step is faster if done on the member portal. |
| Board of Pensions HSA PDG.pdf | |
| COVID Plan Changes Form.pdf | This form allows groups to amend their 2020 and/or 2021 spending account plans with the provisions provided by the Consolidated Appropriations Act, 2021, which was signed into law on December 27, 2020. |
| COVID relief bill overview and key considerations.pdf | This document provides additional guidance for filling out the COVID Plan Changes Form. |
| DCFSA-Claim-Form.pdf | Form that can be used to submit dependent care claims. |
| DCFSA-Enrollment-Form.pdf | Complete this form to enroll a member in a DCFSA. This step is faster if done on the group service center. |
| Debit-Card-Request.pdf | Form that can be used to elect or add dependent debit cards. This step is faster if done on the member portal. |
| Dental-Crossover-Election.pdf | Form that can be used to elect the dental crossover option. This step is faster if done on the member portal. |
| Disband Notice.pdf | The 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.xlsx | Fill 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. |
| Employee HSA Contribution via Payroll Deduction Form.docx | This form can be used by employees to request a change to their payroll deductions for contributing to an HSA. |
| FSA Transfer of Administration Addendum.pdf | By 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. |
| FSA DCFSA Plan Amendment Options Form.pdf | This is a form for groups to amend their 2020 FSA and DCFSA rules regarding extensions of grace periods and rollover amounts. |
| FSA-Direct-Plan-Design-Guide.pdf | Form required to set up a direct FSA. |
| FSA-Enrollment-Form.pdf | Form required to enroll in the Flexible Spending Account/Dependent Care Spending Account. This step is faster if done in the Group Portal. |
| FSA-Plan-Design-Guide.pdf | Form required to set up a new FSA plan. |
| Futher Online Enrollment File Layout.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. |
| Group Plan Change Form.pdf | Use this form to indicate changes for your plan for the upcoming year. |
| Group-ACH-Agreement.pdf | Form required to authorize an administrator to withdraw funds from the employer’s bank account for claim payments, fees or contributions. |
| Group-Contact-Change-Form.pdf | Form required to make changes to the employer’s address, group contact, agency or agent affiliation. |
| Group-Location-Addendum.pdf | Form required to set up multiple locations. |
| Group-Optional-Features-Change-Form.pdf | Form required to make mid-year changes to the health plan information, crossover election, pay the provider option or debit card option. |
| Health Plan Deductible Verification Form.pdf | Use this form to verify your health plan's deductible for the plan year. |
| HRA-Add-Dependent-Form.pdf | Form used to collect active health plan dependents. |
| HRA-Direct-PDG.pdf | Form required to set up a Direct HRA. |
| HRA-Enrollment-Form.pdf | Form required for HRA member enrollment if enrollment is not submitted by your health plan administrator. |
| HRA-Plan-Design-Guide.pdf | Form required to set up your group's HRA plan that must be completed and returned 45 days before the plan's effective date. |
| HRA-Transfer-of-Administration-Addendum.pdf | By 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 Close Account Request Form.pdf | This form helps members close an HSA. |
| HSA Recoupment form.pdf | Form required for an employer to pull funds back from a member’s HSA due to overcontribution or similar error. |
| HSA-Application.pdf | HSA application that can be completed by either group or individual members. This step is faster if done on our website. |
| HSA-Beneficiary-Designation-Form.pdf | Form required to designate, change or remove HSA beneficiaries. This step is faster if done on the member portal. |
| HSA-Contribution-Form.pdf | Form 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.pdf | Form required to set up a Direct HSA. |
| HSA-Distribution-Reclassification-Form.pdf | Complete this form to reclassify member HSA distributions that were reimbursed with the incorrect service type. |
| HSA-Employer-Contribution-Form.pdf | Form that is used by a group when submitting a HSA contribution by check. |
| HSA-Notice-of-Other-Administrator.pdf | Form completed by an employer who has employees with an HSA through another administrator but have an FSA with Further. |
| HSA-Plan-Design-Guide.pdf | Form required to set up an HSA. |
| HSA-Rollover-Certification.pdf | Form required when a member is sending a check from a previous HSA. |
| HSA-Transfer-Form.pdf | Form required to request funds be transferred from another HSA administrator. |
| HSA-Withdrawal-Request.pdf | Form used to request a withdrawal from the HSA. This step is faster if done on the member portal. |
| IRA-Rollover-Request.pdf | Form 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.pdf | Form that can be used to elect the medical crossover option. This step is fastest if done on the member portal. |
| Medical-Expense-Reimbursement-Form.pdf | Form 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. |
| 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. |
| POP-Plan-Design-Guide.pdf | Form required to set up an insurance reimbursement account. |
| PRA-Taxsaver-Claim-Form.pdf | Form that can be used to submit insurance reimbursement claims. This step is fastest if done on the member portal. |
| Premium-Only-Plan-Waiver-Form.pdf | Form completed by an employee to waive coverage in the premium only plan. |
| Premium-Reimbursement-Account-Enrollment-Form.pdf | Form required to enroll in the premium reimbursement plan. |
| Qualifying-Event-Notification-Form.pdf | Form required to request enrollment election changes due to an employee qualifying event. |
| Reimbursement-Return-Form.pdf | Form required to return overpaid funds to a spending account. |
| SA-Appeal.pdf | Form required to file an appeal of a denied claim. |
| SFT Information and Agreement.pdf | Secure File Transfer (SFT) form needed to set up your group's payroll information. |
| Spanish-Authorization-for-Direct-Deposit.pdf | Spanish form that can be used to authorize Further to deposit claim reimbursements directly into your bank account. |
| Spanish-DCFSA-Claim-Form.pdf | Spanish language version of the form that can be used to submit dependent care claims. |
| Spanish-DCFSA-Enrollment-Form-Fillable.pdf | Spanish language version of the form to enroll a member in a DCFSA. This step is faster if done on the group service center. |
| Spanish-Debit-Card-Request.pdf | Spanish form that can be used to elect or add dependent debit cards. |
| Spanish-FSA-Enrollment-Form.pdf | Spanish language form required to enroll in the Flexible Spending Account/Dependent Care Spending Account. This step is faster if done on the group service center. |
| Spanish-HSA Beneficiary Designation Form.pdf | Spanish language form required to designate, change or remove HSA beneficiaries. This step is faster if done on the member portal. |
| Spanish-HSA Contribution Form.pdf | Spanish language form 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. |
| Spanish-HSA Direct PDG.pdf | Spanish language form required to set up a Direct HSA. |
| Spanish-HSA Employer Contribution Form.pdf | Spanish language form that is used by a group when submitting a HSA contribution by check. |
| Spanish-HSA Rollover Certification.pdf | Spanish language form required when a member is sending a check from a previous HSA. |
| Spanish-HSA Transfer Form.pdf | Spanish language form required to request funds be transferred from another HSA administrator. |
| Spanish-HSA-Application.pdf | Spanish HSA application for employer-sponsored HSA plans. |
| Spanish-HSA-Withdrawal-Form.pdf | Form used to request a withdrawal from the HSA. This step is faster if completed on the member portal. |
| Spanish-Letter of Medical Necessity.pdf | Spanish translation version of the form used when proof of medical necessity is required to reimburse an expense. |
| Spanish-Medical Expense Reimbursement Form.pdf | Spanish 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. |
| Spanish-Option-Features-Election.pdf | Spanish form that can be used to elect medical crossover. |
| Spanish-Pay-the-Provider-Crossover-Election.pdf | Opcion Pagar al Proveedor: Spanish form that can be used to authorize the pay-the-provider crossover option. |
| Spanish-Qualifying Event Notification.pdf | Spanish translation version of the form required to request enrollment election changes due to an employee qualifying event. |
| Spanish-Reimbursement Return Form.pdf | Spanish translation version of the form required to return overpaid funds to a spending account. |
| TRA Enrollment Form.pdf | Form for enrolling a member in a TRA. This step is faster if done on the online group service center. |
| TRA-Payroll-Deduction-Report-File-Sample.xlsx | Sample 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.pdf | Form required to set up a Transportation and Parking plan. |
| VEBA Attestation of Waiver of Benefits.pdf | If a VEBA beneficiary would like to waive their rights to an account and designate a new beneficiary or revert the account back to the VEBA trust, this form should be completed. |
| VEBA-Account-Option-Form.pdf | Form that can be used to limit or prevent payments from being made from the VEBA account. |
| VEBA-Add-Dependent-Form.pdf | Form used to collect active health plan dependents. |
| VEBA-Beneficiary-Designation-Form-Fillable.pdf | Form required to designate a VEBA beneficiary. |
| VEBA-Contribution-Form.pdf | Form required for submission of VEBA contributions by check. |
| VEBA-Direct-Plan-Design-Guide.pdf | Form required to set up a Direct VEBA. |
| VEBA-Enrollment-Form.pdf | Form required to enroll employees in the VEBA. |
| Wellness-HRA-Plan-Design-Guide.pdf | Form required to set up a wellness HRA. |