Spending / Savings Account Forms

PDF  Authorization Form - 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 - 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 - Health Reimbursement Account

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

PDF  Dispute Form - Flexible Spending Account - Benny Card

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

PDF  Election Form - Flexible Spending Account

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

PDF  IRS Pub 502 - Medical and Dental Expenses

IRS Publication 502 - Medical and Dental Expenses. ID: 15002Q

PDF  IRS Pub 503 - Child and Dependent Care Expenses

IRS Publication 503 - Child and Dependent Care Expenses. ID: 15004M

PDF  IRS Pub 969 - Health Savings Accounts and Other Tax-Favored Health Plans

IRS Publication 969 - Health Savings Accounts and Other Tax-Favored Health Plans. ID: 24216S

PDF  Letter of Medical Necessity - Flexible Spending Account

Use this form to request a letter of medical necessity for your FSA plan. ID: 6050

PDF  List - 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 - 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 - 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