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CareFirst Learning Site

CareFirst Printable Forms

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

Forms List

File NameDescription
ACH DISPUTE FORM.pdfReview for fraud to determine if money goes back to member.
APPEAL FORM.pdfUsed to submit an appeal on a denial or partial claim denial.
AUTHORIZATION FOR DIRECT DEPOSIT.pdfUsed by member to authorize and add/change bank account for claim reimbursement direct deposit.
BlueFund HSA Payroll Deduction Election.pdfThis form allows your employer to deposit funds from your pay into your health savings account.
CareFirst AAP Expense Claim Form.pdfADOPTION ASSISTANCE REIMBURSEMENT CLAIM FORM Please check all that apply.
CareFirst Electronic Contributions Instructions.pdfGuide and FAQs to create your electronic contribution spreadsheet.
CareFirst Member Overpayment Letter.docxReview for fraud to determine if money goes back to member.
Complete to enroll a group in an HRA plan.pdfUsed by group to request recoup on contributions for various reasons e.g., contributions exceeded regulatory limits.
DAYCARE EXPENSE REIMBURSEMENT CLAIM FORM.pdfForm that can be used to submit dependent care claims.
ELECTRONIC ACH EFT OR 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
Electronic Deduction and Contribution Template Carefirst.xlsxThis document provides file upload specifications for uploading HSA contribution information for members.
FSA Electronic Enrollment Template.xlsxUse this spreadsheet to enroll members in an FSA or update their information.
Health Reimbursement Arrangement (HRA) Plan Design Guide.pdfComplete to enroll a group in an HRA plan.
Health Savings Account (HSA) Plan Design Guide.pdfComplete to enroll a group in an HSA plan.
Health Savings Account (HSA) Transfer Instructions.pdfComplete the form included here to transfer funds from another account into a CareFirst HSA.
HEALTH SAVINGS ACCOUNT CONTRIBUTION FORM.pdfUsed by member to request how HSA contribution will be made via check or electronic fund transfer
HEALTH SAVINGS ACCOUNT WITHDRAWAL REQUEST.pdfUsed by member to withdraw HSA funds.
LETTER OF MEDICAL NECESSITY (LOMN) .pdfUsed by member to identify if a potentially eligible claim can be paid.
MEDICAL EXPENSE REIMBURSEMENT ACCOUNT CLAIM FORM.pdfForm used for eligible expenses incurred by members or their eligible dependents for an HRA or HIA account.
RECLASSIFICATION OF HSA FUNDS.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.
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.

 

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