Spending / Savings Account

PDF  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

PDF  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

PDF  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

PDF  Authorization Form - Spending-Savings Accounts - Flexible Spending Account - Direct Deposit

This form authorizes Horizon BCBSNJ to make a bank account deposit for a Flexible Spending Account (FSA). ID: 8314

PDF  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

PDF  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

PDF  Claim Form - Spending-Savings Accounts - Health Reimbursement Account

This form is used to file a Horizon Health Reimbursement Account (HRA MyWay) claim. ID: 2816

PDF  Confirmation Form - Spending-Savings Accounts - Health Savings Account Funding

This form is used to provide confirmation of Health Savings Account (HSA) funding. ID: 5890

PDF  Cost Summary - Spending-Savings Accounts - Flexible Spending Account (500 Plus)

Cost summary for Flexible Spending Accounts (FSA) of 500+. ID: 16120

PDF  Cost Summary - Spending-Savings Accounts - Flexible Spending Account (Fewer than 500)

Cost summary for Flexible Spening Accounts (FSA). ID: 16119

PDF  Dispute Form - Spending-Savings Accounts - Flexible Spending Account - Benny Card

Use this form to file a Benny Card transaction dispute. ID: 8303

PDF  Election Form - Spending-Savings Accounts - Flexible Spending Account

Use this form to enroll in an Unreimbursed Medical or Dependent Care Flexible Spending Account. ID: 8997

PDF  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

PDF  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

PDF   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

PDF  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

PDF  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