Surency Forms

Whether you have a Surency Vision plan or Surency Flex plan, find applicable forms below to help manage your account.

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Surency Flex FSA/HRA Claim Form (2024)

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Surency Flex Travel Benefit Claim Form

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Surency Flex Individual HSA Election Change Form

Surency Flex Individual HSA Election Change Form

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Surency Flex FSA Bancorp (ACH Payments) Bank Form

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Surency Flex HRA Recurring Premium Reimbursement Request Form

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Surency Flex HSA Blocked Account Verification Form

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Surency Flex Health Savings Brokerage Account - Limited Power of Attorney Agreement

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Surency Flex FSA Balance Forfeiture Form

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Surency Flex HSA Election Change Form

Surency Flex HSA Election Change Form

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Surency Flex HSA Information Authorization Form

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Surency Flex HSA Distribution-HRA Claim Form

Surency Flex HSA Distribution-HRA Claim Form

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Surency Flex Termination/Status Change Form

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Surency Broker Account Registration Form

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Surency Flex HRA Renewal Form

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Surency Flex HSA Renewal Form

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Surency Flex Appeal Request Form

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Surency Flex Authorization for Disclosure of Protected Health Information (HIPAA) Form

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Surency Flex Additional Benefits Card Request Form

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Surency Flex Employer Account Registration Form

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Surency Flex Benefits Card Transaction Dispute Form

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Surency Flex FSA/Dependent Care FSA Renewal Form

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Surency Flex Direct Deposit Authorization Form

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Surency Flex HSA Distribution Request Form

Surency Flex HSA Distribution Request Form

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Surency Flex Qualified Small Employer HRA Claim Form

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Surency Flex Transit Expense Reimbursement Request Form

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Surency Flex Parking Expense Reimbursement Request Form

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Surency Flex HSA Transfer Form

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Surency Flex HSA Power of Attorney Form

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Surency Flex HSA Information Change Notification Form

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Surency Flex HSA Death Distribution Request Form

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Surency Flex HSA Contribution Form

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Surency Flex HSA Beneficiary Change/Spousal Consent Form

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Surency Flex Receipt & Substantiation Form

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Surency Flex Orthodontia Claim Form

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Surency Flex HRA Deductible Verification Form

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Surency Flex FSA/HRA Claim Form (2022)

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Surency Flex FSA Deductible Verification Form

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Surency Flex Capital Expense Worksheet

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Surency Flex Dependent Care Reimbursement Form

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Surency Flex Dependent Care Receipt Form

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Surency Flex Claims Run In Form

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Surency Flex Letter of Medical Necessity Form

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