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 Employer Bank Agreement 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 COBRA Direct Billing Renewal Worksheet (Expanded)
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Surency COBRA Direct Billing Renewal Worksheet (Condensed)
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Surency COBRA Social Security Disability Extension (SSDE) Form
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Surency COBRA Second Qualifying Event Form
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Surency COBRA Retiree/Participant Information Form
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Surency COBRA Renewal Worksheet (Expanded)
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Surency COBRA Renewal Worksheet (Condensed)
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Surency COBRA Implementation Worksheet
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Surency COBRA Employer Account Registration Form
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Surency COBRA Direct Billing Implementation Worksheet
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Surency COBRA Benefits Termination Form
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Surency Flex Temporary Change Request Notification Form
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Surency Flex FSA/DC FSA COVID-19 Relief Temporary Change Request Notification Form
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Surency Flex Dependent Care FSA ARPA Change Request Notification Form
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Surency Flex FSA Balance Forfeiture Form
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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
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Surency COBRA Appeal Request Form
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Surency COBRA Authorization for Disclosure of Protected Health Information (HIPAA) Form
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Surency Vision Authorization for Disclosure of Protected Health Information (HIPAA) Form
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Surency Flex Termination/Status Change Form
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Surency Vision COBRA Billing Designation Form
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Surency Vision COBRA Continuation of Group Vision Coverage Form
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Surency Vision Enrollment/Change 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 Vision Nominate a Provider 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 Vision Employer Account Registration 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
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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 Direct Deposit Enrollment/Change 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
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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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Surency Vision State of Kansas Employees Out-of-Network Claim Form
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