FSA Claim Forms

Flexible Spending Account (FSA) Claim Forms

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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:

Mail:

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

Fax:
1-888-666-1221

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