CareFirst Printable Forms
This page contains printable forms that you can use to manage your account.
Forms List
| File Name | Description |
|---|---|
| ACH DISPUTE FORM.pdf | Review for fraud to determine if money goes back to member. |
| APPEAL FORM.pdf | Used to submit an appeal on a denial or partial claim denial. |
| AUTHORIZATION FOR DIRECT DEPOSIT.pdf | Used by member to authorize and add/change bank account for claim reimbursement direct deposit. |
| BlueFund HSA Payroll Deduction Election Form.pdf | This form allows your employer to deposit funds from your pay into your health savings account. |
| CareFirst AAP Expense Claim Form.pdf | ADOPTION ASSISTANCE REIMBURSEMENT CLAIM FORM Please check all that apply. |
| CareFirst Electronic Contributions Instructions.pdf | Guide and FAQs to create your electronic contribution spreadsheet. |
| CareFirst Health Savings Account Contribution Recoupment Form.pdf | Used by group to request recoup on contributions for various reasons e.g., contributions exceeded regulatory limits. |
| CareFirst Member Overpayment Letter.docx | Review for fraud to determine if money goes back to member. |
| DAYCARE EXPENSE REIMBURSEMENT CLAIM FORM.pdf | Form that can be used to submit dependent care claims. |
| Electronic Deduction and Contribution Template Carefirst.xlsx | This document provides file upload specifications for uploading HSA contribution information for members. |
| FSA Electronic Enrollment Template.xlsx | Use this spreadsheet to enroll members in an FSA or update their information. |
| FSA Fact Sheet CareFirst.pdf | Flexible Spending Account (FSA) FAQs |
| Health Reimbursement Arrangement (HRA) Plan Design Guide.pdf | Complete to enroll a group in an HRA plan. |
| Health Savings Account (HSA) Plan Design Guide.pdf | Complete to enroll a group in an HSA plan. |
| HEALTH SAVINGS ACCOUNT CONTRIBUTION FORM.pdf | Used by member to request how HSA contribution will be made via check or electronic fund transfer |
| HEALTH SAVINGS ACCOUNT WITHDRAWAL REQUEST.pdf | Used by member to withdraw HSA funds. |
| HSA Fact Sheet CareFirst.pdf | Health Savings Account (HSA) FAQs |
| HSA Transfer form.pdf | Complete the form included here to transfer funds from another account into a CareFirst HSA. |
| LETTER OF MEDICAL NECESSITY (LOMN) .pdf | Used by member to identify if a potentially eligible claim can be paid. |
| MEDICAL EXPENSE REIMBURSEMENT ACCOUNT CLAIM FORM.pdf | Form used for eligible expenses incurred by members or their eligible dependents for an HRA or HIA account. |
| Premium Only Plan (POP).pdf | Premium Only Plan | Plan Design Guide |
| RECLASSIFICATION OF HSA FUNDS.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. |
| 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. |
| TRA Essential Guide.pdf | A transportation reimbursement account (TRA) helps you save money on transportation and parking expenses while commuting to and from work. |
| TRA Fact Sheet.pdf | Transportation Reimbursement Arrangement (TRA) FAQs. |
| View the Blue Rewards Cardholder Agreement.pdf | CARDHOLDER AGREEMENT. Terms and Conditions/Definitions for the CareFirst Blue Rewards Visa® Incentive Card |
| View the BlueFund Cardholder Agreement.pdf | Cardholder Agreement. Terms and Conditions / Definitions for the BlueFund® Visa® Debit Card |