Horizon MyWay
Access printable forms that you can use to manage your Horizon MyWay account.
Horizon MyWay Health Savings Account (HSA) Withdrawal Request
Used for requesting distribution from a Health Savings Account (HSA).
ID: X22165 (11/18)
Horizon MyWay Medical Expense Reimbursement Account Claim Form
Use this form for eligible expenses incurred by you or your eligible dependents.
ID: X22715 (10/18)
Horizon Letter of Medical Necessity
Under Internal Revenue Service rules, some health care services and products are only eligible for reimbursement from your spending account when your doctor or eligible licensed health care provider certifies that they are medically necessary. Please use this letter to provide the information needed to process your claim. Your provider must indicate the patient’s diagnosis, the recommended treatment needed, and how this treatment will alleviate the medical condition. Be sure to send this LOMN with your completed medical reimbursement form.
ID: X22138
Horizon MyWay Daycare Expense Reimbursement Claim Form
Use this form for dependent child or adult daycare expenses.
ID: X22714 (11/18)
