Your medical care provider must complete a Letter of Medical Necessity for any service or product that falls under the
category of “Possible Expense” or “Ineligible Expense” per IRC section 213(d)(1) if your provider believes the service or
product is medically necessary for you or your tax dependent(s).
TO BE COMPLETED BY PARTICIPANT
Participant Name:________________________________________________ ______________________ ___________
Last First MI
Participant Employer: _______________________________________________________________________________
Participant ID#: _______________________________________ Participant Phone #: _______ - _______- __________
PatientName: ___________________________________________________ ______________________ ___________
Last First MI
TO BE COMPLETED BY LICENSED PRACTITIONER
Medical Condition: _________________________________________________________________________________
________________________________________________________________________________________________
Please describe treatment (frequency and/or dosage): _____________________________________________________
_____________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Duration of Treatment: ______________________________________________________________________________
I certify that this service or product is medically necessary to treat the specific medical condition described above and is
not in any way for general health or for cosmetic purposes.
Print Name of Licensed Practitioner: ___________________________________________________________________
Signature of Licensed Practitioner: ____________________________________________________________________
Date: _____ / _____ / ________
MM DD YYYY
NOTE: In order for the expense referred to on this Letter of Medical Necessity form to be reimbursed, you the participant
must attach the detailed receipt of explanation of Benefit from you medical insurance carrier and complete a FSAClaim
Form for Reimbursement (certain expenses may require additional documentation). Documentation must include the date of
service and amount charged. These documents are required with each claim that is filed.
Horizon Blue Cross Blue Shield of New Jersey
3 Penn Plaza East PP-08S
Newark, NJ 07105-2200
(800) 224-4426
Fax 973-274-2215
HorizonBlue.com/fsa
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.
6050 (W1015)
Letter of Medical Necessity
You may complete the required fields below online and then save or print a copy for submission. To save a completed copy to your computer,
choose File > Save As to rename the file and save the form with your information to your computer.
RESET
Three Penn Plaza East
Newark, NJ 07105-2200
HorizonBlue.com
CMC0008179 (0616)
An Independent Licensee of the
Blue Cross and Blue Shield Association.
Notice of Nondiscrimination
Horizon Blue Cross Blue Shield of New Jersey complies with applicable Federal civil rights laws
and does not discriminate on the basis of race, color, national origin, age, disability or sex.
Horizon BCBSNJ does not exclude people or treat them differently because of race, color,
national origin, age, disability or sex.
Horizon BCBSNJ provides free aids and services to people with disabilities to communicate
effectively with us, such as:
• Qualified sign language interpreters
• Information written in other languages
If you need these services, contact Horizon BCBSNJ’s Director of Regulatory Compliance at the
phone number, fax or email listed below.
If you believe that Horizon BCBSNJ has failed to provide these services or discriminated in
another way on the basis of race, color, national origin, age, disability or sex, you can file a
grievance with:
Horizon BCBSNJ – Director, Regulatory Compliance
Three Penn Plaza East, PP-16C
Newark, NJ 07105
Phone: 1-800-658-6781
Fax: 1-973-466-7759
You can file a grievance in person, or by mail, fax or email. If you need help filing a grievance,
Horizon BCBSNJ’s Director of Regulatory Compliance is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human
Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint
Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
Office for Civil Rights Headquarters
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019 or 1-800-537-7697 (TDD)
Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.
CMC0007942 (0516)
An Independent Licensee of the
Blue Cross and Blue Shield Association.
If you need help understanding this Horizon Blue Cross Blue Shield of New Jersey information,
you have the right to get help in your language at no cost to you. To talk to an interpreter, please
call 1-800-355-BLUE (2583) during normal business hours.
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Gujarati ( ):
, ,
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Blue Shield of New Jersey, avete diritto ad assistenza gratis nella vostra lingua. Per parlare con
un interprete, siete pregati di telefonare al numero 1-800-355-BLUE (2583) durante le normali
ore d’ufficio.
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Blue Cross Blue Shield of New Jersey, may karapatan kang humingi ng tulong sa iyong wika
nang walang gastos sa iyo. Upang makipag-usap sa isang taga-interpret, mangyaring tumawag sa
1-800-355-BLUE (2583) sa loob ng karaniwang mga oras ng negosyo.
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предоставленной компанией Horizon Blue Cross Blue Shield of New Jersey, у вас есть право
на получение помощи на вашем родном языке бесплатно. Для связи с переводчиком
звоните по номеру телефона 1-800-355-BLUE (2583) в обычные рабочие часы.
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Blue Cross Blue Shield of New Jersey, ou gen dwa pou jwenn èd nan lang natifnatal ou
gratis. Pou pale avèk yon entèprèt, tanpri rele nimewo 1-800-355-BLUE (2583) pandan lè nòmal
biznis.
Hindi ( ):
1-800-355-BLUE (2583)
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Blue Cross Blue Shield of New Jersey, quý vị có quyền được giúp đỡ bằng ngôn ngữ của mình
miễn phí. Xin gọi số 1-800-355-BLUE (2583) trong giờ làm việc để nói chuyện với người
thông dịch.
French (Français): Si vous avez besoin d’assistance pour comprendre ces informations au sujet de
Horizon Blue Cross Blue Shield of New Jersey, vous avez le droit d’obtenir de l’aide dans votre
langue, sans aucun frais. Pour parler avec un interprète, veuillez appeler le 1-800-355-BLUE (2583)
pendant les heures normales de bureau.
Navajo (Diné): D77 New Jersey bi[ hahoodzo Horizon Blue Cross Blue Shield, t’11 ninizaad
k’ehj7 baa hane’77 bik’i diit88h bee shik1’ a’doowo[ n7n7zingo 47 bee n1’ahoot’i’ d00 doo b33h 7l7n7
da. Ata’ halne’4 [a’ bich’8’ hadeesdzih n7n7zingo t’11 sh--d7 1-800-355-BLUE (2583)j8’
nida’anishgo oolki[77 bik’ehgo hod77lnih.
ArabicHorizon Blue Cross Blue Shield of New Jersey
1-800-355-BLUE (2583)
Urdu)(
1-800-355-BLUE (2583)
