Skip to main content

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: X22713

PDF  Claim Form - Flexible Spending Account - Dependent Care

This form is used to file a Horizon BCBSNJ Flexible Spending Account (FSA) claim. ID: X22715

PDF  Claim Form - Flexible Spending Account - Medical

This form is used to file a Horizon BCBSNJ Flexible Spending Account (FSA) claim. ID: X22714

PDF  Claim Form - Health Reimbursement Account

This form is used to file a Horizon Health Reimbursement Account (HRA MyWay) claim. ID: X22715

PDF  Election Form - Flexible Spending Account

Use this form to enroll in an Unreimbursed Medical or Dependent Care Flexible Spending Account. ID: X22125

PDF  Letter of Medical Necessity - Flexible Spending Account

Use this form to request a letter of medical necessity for your FSA plan. ID: X22138

PDF  List - Flexible Spending Account - Dependent Expenses

This is a list of some of the medical expenses eligible for payment under the Unreimbursed Medical Spending Account. ID: EC00750

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: EC00749

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