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Spending / Savings Account Forms

IRS Pub 502 - Medical and Dental Expenses › IRS Publication 502 - Medical and Dental Expenses. ID: 15002Q opens in a new window
IRS Pub 503 - Child and Dependent Care Expenses › IRS Publication 503 - Child and Dependent Care Expenses. ID: 15004M opens in a new window
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 opens in a new window

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