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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
2024 FSA Employer Sheet.pdfHorizon MyWay makes FSAs easy for you—and your employees!
2024 FSA Fact Sheet.pdfFlexible Spending Accounts (FSA) Fact Sheet
2024 FSA Worksheet.pdfFlexible Spending Account Worksheet
ACH ADDENDUM.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.pdfThis form must be filled out to dispute a transaction on an ACH account.
APPEAL FORM.pdfThis form must be filled out if a Member wants to appeal a denied claim.
AUTHORIZATION FOR DIRECT DEPOSIT.pdfAllows members to electronically receive funds directly into their banking account instead of using a paper check.
DAYCARE EXPENSE REIMBURSEMENT CLAIM FORM.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.
FSA Renewal Change Form.pdfUse this form to change the contribution details of your FSA.
FSA TRANSFER OF ADMINSITRATION ADDENDUM.pdfAddendum to the form allowing Horizon to take over administration of an FSA.
FTP SETUP FORM.pdfAllows files to be transferred securely via the internet.
HEALTH SAVINGS ACCOUNT CONTRIBUTION FORM.pdfThis form allows members to create either a one-time or recurring contribution to their HSA from a traditional checking or savings account.
HEALTH SAVINGS ACCOUNT CONTRIBUTION RECOUPMENT FORM.pdfForm required for an employer to pull funds back from a member’s HSA due to overcontribution or similar error.
HEALTH SAVINGS ACCOUNT ROLLOVER CERTIFICATION.pdfThis form is for rolling over HSA funds and MSA funds.
HEALTH SAVINGS ACCOUNT TRANSFER REQUEST.pdfUse this form to transfer HSA funds from another administrator to Horizon.
HEALTH SAVINGS ACCOUNT WITHDRAWAL REQUEST.pdfUse this form to withdrawal funds from an HSA.
Horizon FSA PDG.pdfFlexible Spending Account Plan Design Guide
Horizon Group Contact Change Form.pdfUse this form to update the contact person for your group.
HRA RENEWAL CHANGE FORM.pdfAllows groups who automatically renew to make a change to their FSA plan.
HRA TRANSFER OF ADMINISTRATION ADDENDUM.pdfAddendum to the form allowing Horizon to take over administration of an HRA.
HSA BENEFICIARY DESIGNATION FORM.pdfThis form allows members to change or add to the beneficiaries of their HSA.
HSA INVESTMENT ELECTION FORM.pdfUse this form to choose or make changes to HSA investment elections.
LETTER OF MEDICAL NECESSITY (LOMN).pdfThis form must be filled out by a member and doctor for some purchases to be eligible for reimbursement.
LIMITED PURPOSE FSA ADDENDUM.pdfAddendum to the plan design guide to allow a group to add a limited-purpose FSA plan.
MEDICAL EXPENSE REIMBURSEMENT ACCOUNT CLAIM FORM.pdfSubmit this form to file a reimbursement claim.
Medical FSA Enrollment Form.pdfAllows members to enroll in a medical FSA or dependent care FSA plan.
MEMBER REQUESTED AUTHORIZATION FOR RELEASE OF INFORMATION.pdfThis form authorizes Horizon to share certain member information to specified people.
ONE TIME IRA TO HSA ROLLOVER REQUEST.pdfUse this form to rollover funds from an IRA into an HSA.
QUALIFYING EVENT NOTIFICATION FORM.pdfUse this form when a change needs to be made to a member's plan outside of open enrollment because of a qualifying event.
RECLASSIFICATION OF HSA FUNDS.pdfUse this form to reclassify an HSA distribution with an incorrect service type.
REIMBURSEMENT RETURN FORM.pdfUse this form if a reimbursement must be returned to Horizon.
SECURE FILE TRANSFER INFORMATION.pdfThis form must be filled out before a secure file transfer can take place.


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