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Horizon CDH Learning Site

Horizon Printable Forms

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

Forms List

File NameDescription
ACH Addendum Form.pdfAddendum 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.pdfThis form must be filled out to dispute a transaction on an ACH account.
Appeal Form - Horizon.pdfThis form must be filled out if a Member wants to appeal a denied claim.
Authorization for Direct Deposit - Horizon.pdfAllows members to electronically receive funds directly into their banking account instead of using a paper check.
DCAP Claim Form - Horizon.pdfFill out this form and submit it with your dependent care claim to receive your reimbursement.
Electronic Contribution Instructions Horizon.pdfThis document provides instructions and guidance for creating a contribution upload file.
Electronic Deduction and Contribution Template Horizon.xlsxThis document provides file upload specifications for uploading HSA contribution information for members.
Employee Contribution Election Form-HSA.docxUsed by groups to collect employee withholding amounts.
FSA and DCAP Enrollment Form - Horizon.pdfAllows members to enroll in a medical FSA or dependent care FSA plan.
FSA Direct Plan Guide HR0921.pdfUsed by a group to design an FSA.
FSA Renewal Change Form-Horizon.pdfAllows groups who automatically renew to make a change to their FSA plan.
FSA Transfer of Administration Addendum - Horizon.pdfAddendum to the form allowing Horizon to take over administration of an FSA.
FTP Setup Form - Horizon.pdfAllows files to be transferred via the internet
Group Trustee Transfer Form - Horizon.docxFill out when closing at BenefitWallet account and transferring funds to Further
HRA Direct Plan Guide 1001e.pdfUsed by a group to design an HRA.
HRA Renewal Change Form-Horizon.pdfAllows groups who automatically renew to make a change to their HRA plan.
HRA Transfer of Administration Addendum - Horizon.pdfAddendum t othe form allowing Horizon to take over administration of an HRA.
HSA and MSA Rollover Certification Form - Horizon.pdfThis form is for rolling over HSA funds and MSA funds.
HSA Beneficiary Designation Form - Horizon.pdfThis form allows members to change or add to the beneficiaries of their HSA.
HSA Contribution Form - Horizon.pdfThis form allows members to create either a one-time or recurring contribution to their HSA from a traditional checking or savings account.
HSA Direct Plan Guide HR0921.pdfUsed by a group to design an HSA.
HSA Group Contribution Submission Form - Horizon.pdfUse this form to submit a group HSA contribution from employees and/or an employer.
HSA Investment Account Transaction Form - Horizon.pdfWhen 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.pdfUse this form to choose or make changes to HSA investment elections.
HSA Reclassification of Funds Form - Horizon.pdfUse this form to reclassify an HSA distribution with an incorrect service type.
HSA Transfer Request Form - Horizon.pdfUse this form to transfer HSA funds from another administrator to Horizon.
HSA Withdrawal Request Form - Horizon.pdfUse this form to withdrawal funds from an HSA.
Letter of Medical Necessity - Horizon.pdfThis form must be filled out by a member and doctor for some purchases to be eligible for reimbursement.
Limitied Purpose FSA Addendum-Horizon.pdfAddendum to the plan design guide to allow a group to add a limited-purpose FSA plan.
Medical Expense Reimbursement Claim Form - Horizon.pdfSubmit this form to file a reimbursement claim.
Non-Discrimination Testing Request Form - Horizon.pdfComplete this form to allow us to administer testing to ensure your plans are compliant.
One-Time IRA to HSA Rollover Form - Horizon.pdfUse this form to rollover funds from an IRA into an HSA.
Qualifying Event Notification Form - Horizon.pdfUse 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.pdfUse this form if a reimbursement must be returned to Horizon.
Secure File Transfer Info Agreement Form.pdfThis form must be filled out before a secure file transfer can take place.
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