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FSA Claim Forms

Flexible Spending Account (FSA) Claim Forms

(You will need Adobe Acrobat Reader to view or print items on this page.)

FSA reimbursement requests can be made using the applicable claim form above.

Simply complete and sign the claim form and attach one of the following:

  • Your Explanation of Benefits from BlueCross BlueShield of Tennessee, or
  • Receipts for prescriptions, health-related expenses or dependent care expenses.

Completed reimbursement requests should be mailed or faxed to:


BlueCross BlueShield of Tennessee
Claims Service Center
1 Cameron Hill Circle Ste 0022
Chattanooga, TN  37402-0022


Because these benefits are optional, please check your Evidence of Coverage or your employer’s summary plan description to make sure you have a BlueCross BlueShield of Tennessee FSA.

Page Modified:May 18, 2012