Form 6518 (W0407) - Claim For Reimbursement - Horizon Blue Cross Blue Shield
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1
2Horizon Blue Cross Blue Shield of New Jersey
3 Penn Plaza East PP-05S
Newark, NJ 07105-2200
(800) 224-4426
Fax 973-274-2215
CLAIM FOR REIMBURSEMENT
Company Name ________________________________________ ID # _________________________________
Your Name ____________________________________________ Phone # ______________________________
Home Address _________________________________________ City ____________State _____ Zip _________
Check here if new address
DEPENDENT CARE (DAYCARE) EXPENSE CLAIMS
Period Covered
Name and Address of
Taxpayer ID
Amount
Name of Dependent(s)
From
To
Provider of Service
or Member ID
Incurred
UNREIMBURSED MEDICAL EXPENSE CLAIMS
Name of Service
Expense
*No Ins.
Date Expense Incurred
Person for Whom Expense Incurred
Net Amount
Coverage (Initial)
Provider
Description
Total Medical Care Expenses Claimed
Read Carefully: The undersigned participant in the plan certifies that all expenses for which reimbursement or payment is claimed by
submission of this form were incurred during a period while the undersigned was covered under the company Flexible
Spending Account Plan with respect to such expenses and that the medical expenses have not been reimbursed or are not
reimbursable under any other health plan coverage. The undersigned fully understands that (s)he alone is fully responsible
for the sufficiency, accuracy and veracity of all information relating to this claim which is provided by the undersigned, and that
unless an expense for which payment or reimbursement is claimed is a proper expense under the plan, the undersigned may
be liable for payment of all related taxes including federal, state, or city income tax on amounts paid from the plan which relate
to such expense.
*No insurance coverage for expense - please initial.
__________________________________________________________________________________ ______________________________
Employee’s Signature
Date
Services and Products may be provided by Horizon Blue Cross Blue Shield of New Jersey, an independent licensee of the Blue Cross and Blue Shield Association.
6518 (W0407)
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