Horizon Printable Forms
This page contains printable forms that you can use to manage your account.
Forms List
| File Name | Description |
|---|---|
| 2024 FSA Employer Sheet.pdf | Horizon MyWay makes FSAs easy for you—and your employees! |
| 2024 FSA Fact Sheet.pdf | Flexible Spending Accounts (FSA) Fact Sheet |
| 2024 FSA Worksheet.pdf | Flexible Spending Account Worksheet |
| ACH ADDENDUM.pdf | Addendum 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.pdf | This form must be filled out to dispute a transaction on an ACH account. |
| APPEAL FORM.pdf | This form must be filled out if a Member wants to appeal a denied claim. |
| AUTHORIZATION FOR DIRECT DEPOSIT.pdf | Allows members to electronically receive funds directly into their banking account instead of using a paper check. |
| DAYCARE EXPENSE REIMBURSEMENT CLAIM FORM.pdf | Fill out this form and submit it with your dependent care claim to receive your reimbursement. |
| Electronic Contribution Instructions Horizon.pdf | This document provides instructions and guidance for creating a contribution upload file. |
| Electronic Deduction and Contribution Template Horizon.xlsx | This document provides file upload specifications for uploading HSA contribution information for members. |
| FLEXIBLE SPENDING ACCOUNT (FSA) PLAN DESIGN GUIDE.pdf | Used by a group to design an FSA. |
| FSA Renewal Change Form.pdf | Use this form to change the contribution details of your FSA. |
| FSA TRANSFER OF ADMINSITRATION ADDENDUM.pdf | Addendum to the form allowing Horizon to take over administration of an FSA. |
| FTP SETUP FORM.pdf | Allows files to be transferred securely via the internet. |
| HEALTH REIMBURSEMENT ARRANGEMENT (HRA) PLAN DESIGN GUIDE.pdf | Used by a group to design an HRA. |
| HEALTH SAVINGS ACCOUNT CONTRIBUTION FORM.pdf | This 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.pdf | Form required for an employer to pull funds back from a member’s HSA due to overcontribution or similar error. |
| HEALTH SAVINGS ACCOUNT ROLLOVER CERTIFICATION.pdf | This form is for rolling over HSA funds and MSA funds. |
| HEALTH SAVINGS ACCOUNT TRANSFER REQUEST.pdf | Use this form to transfer HSA funds from another administrator to Horizon. |
| HEALTH SAVINGS ACCOUNT WITHDRAWAL REQUEST.pdf | Use this form to withdrawal funds from an HSA. |
| Horizon FSA PDG.pdf | Flexible Spending Account Plan Design Guide |
| Horizon Group Contact Change Form.pdf | Use this form to update the contact person for your group. |
| HRA RENEWAL CHANGE FORM.pdf | Allows groups who automatically renew to make a change to their FSA plan. |
| HRA TRANSFER OF ADMINISTRATION ADDENDUM.pdf | Addendum to the form allowing Horizon to take over administration of an HRA. |
| HSA BENEFICIARY DESIGNATION FORM.pdf | This form allows members to change or add to the beneficiaries of their HSA. |
| HSA INVESTMENT ELECTION FORM.pdf | Use this form to choose or make changes to HSA investment elections. |
| LETTER OF MEDICAL NECESSITY (LOMN).pdf | This form must be filled out by a member and doctor for some purchases to be eligible for reimbursement. |
| LIMITED PURPOSE FSA ADDENDUM.pdf | Addendum to the plan design guide to allow a group to add a limited-purpose FSA plan. |
| MEDICAL EXPENSE REIMBURSEMENT ACCOUNT CLAIM FORM.pdf | Submit this form to file a reimbursement claim. |
| Medical FSA Enrollment Form.pdf | Allows members to enroll in a medical FSA or dependent care FSA plan. |
| MEMBER REQUESTED AUTHORIZATION FOR RELEASE OF INFORMATION.pdf | This form authorizes Horizon to share certain member information to specified people. |
| ONE TIME IRA TO HSA ROLLOVER REQUEST.pdf | Use this form to rollover funds from an IRA into an HSA. |
| QUALIFYING EVENT NOTIFICATION FORM.pdf | Use 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.pdf | Use this form to reclassify an HSA distribution with an incorrect service type. |
| REIMBURSEMENT RETURN FORM.pdf | Use this form if a reimbursement must be returned to Horizon. |
| SECURE FILE TRANSFER INFORMATION.pdf | This form must be filled out before a secure file transfer can take place. |