Spending / Savings Account
Application - Spending-Savings Accounts - Flexible Spending Account
Employers & Brokers use this form to apply to establish a cafeteria plan under Section 125 of the Internal Revenue Code. ID: 8316
Authorization Form - Spending-Savings Accounts - Flexible Spending Account - Debit Monthly Administrative Fees
This form authorizes Horizon BCBSNJ to debit a bank account for Flexible Spending Account (FSA) administrative fees. ID: 8415
Authorization Form - Spending-Savings Accounts - Flexible Spending Account - Debit Reimbursements
This form authorizes Horizon BCBSNJ to debit a bank account for Flexible Spending Account (FSA) reimbursements. ID: 8414
Claim Form - Spending-Savings Accounts - Flexible Spending Account - Medical and Dependent Care
This form is used to file a Horizon BCBSNJ Flexible Spending Account (FSA) claim. ID: 6051
Claim Form - Spending-Savings Accounts - Flexible Spending Account - Transportation
Use this form to file a Horizon BCBSNJ Flexible Spending Account (FSA) transportation expenses claim. ID: 132
Claim Form - Spending-Savings Accounts - Health Reimbursement Account
This form is used to file a Horizon Health Reimbursement Account (HRA MyWay) claim. ID: 2816
Confirmation Form - Spending-Savings Accounts - Health Savings Account Funding
This form is used to provide confirmation of Health Savings Account (HSA) funding. ID: 5890
Cost Summary - Spending-Savings Accounts - Flexible Spending Account (500 Plus)
Cost summary for Flexible Spending Accounts (FSA) of 500+. ID: 16120
Cost Summary - Spending-Savings Accounts - Flexible Spending Account (Fewer than 500)
Cost summary for Flexible Spening Accounts (FSA). ID: 16119
Dispute Form - Spending-Savings Accounts - Flexible Spending Account - Benny Card
Use this form to file a Benny Card transaction dispute. ID: 8303
Letter of Medical Necessity - Spending-Savings Accounts - Flexible Spending Account
Use this form to request a letter of medical necessity for your FSA plan. ID: 6050
List - Spending-Savings Accounts - Flexible Spending Account - Eligible Expenses
This is a list of some of the medical expenses eligible for payment under the Unreimbursed Medical Spending Account. ID: 8315
List - Spending-Savings Accounts - Flexible Spending Account - OTC Drug Changes Effective Jan 1 2011
This list gives an overview of some of the over-the-counter (OTC) drugs for which a prescription is required to qualitfy under flexible spending accounts (FSA), health reimbursement accounts (HRAs) and health savings accounts (HSAs). ID: 6827
Notification Form - Spending-Savings Accounts - Flexible Spending Account - Change In Status
Have a change in family status? This form can initiate or change a salary deduction for an Unreimbursed Medical Spending Account or a Dependent Care Spending Account. ID: 16374
Request Form – Merck Members – Flexible Spending Account – Check Reissue
If a Flexible Spending Account (FSA) reimbursement check is not received, this form is used to request a new one. ID: 16115