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 (2023)

Surency Flex FSA/HRA Claim Form (2023)

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Surency Vision Maternity Benefit Self-Report Form

Surency Vision Maternity Benefit Self-Report Form

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Surency Flex Travel Benefit Claim Form

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 COBRA Client Remittance Form

Surency COBRA Client Remittance Form

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Surency Flex FSA Employer Bank Agreement Form

Surency Flex FSA Employer Bank Agreement Form

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Surency Flex FSA Bancorp (ACH Payments) Bank Form

Surency Flex FSA Bancorp (ACH Payments) Bank Form

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Surency Flex HRA Recurring Premium Reimbursement Request Form

Surency Flex HRA Recurring Premium Reimbursement Request Form

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Surency Flex HSA Blocked Account Verification Form

Surency Flex HSA Blocked Account Verification Form

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

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

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Surency COBRA Direct Billing Renewal Worksheet (Expanded)

Surency COBRA Direct Billing Renewal Worksheet (Expanded)

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Surency COBRA Direct Billing Renewal Worksheet (Condensed)

Surency COBRA Direct Billing Renewal Worksheet (Condensed)

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Surency COBRA Social Security Disability Extension (SSDE) Form

Surency COBRA Social Security Disability Extension (SSDE) Form

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Surency COBRA Second Qualifying Event Form

Surency COBRA Second Qualifying Event Form

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Surency COBRA Participant or Retiree Enrollment Form

Surency COBRA Participant or Retiree Enrollment Form

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Surency COBRA Renewal Worksheet (Expanded)

Surency COBRA Renewal Worksheet (Expanded)

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Surency COBRA Renewal Worksheet (Condensed)

Surency COBRA Renewal Worksheet (Condensed)

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Surency COBRA Implementation Worksheet

Surency COBRA Implementation Worksheet

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Surency COBRA Employer Account Registration Form

Surency COBRA Employer Account Registration Form

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Surency COBRA Direct Billing Implementation Worksheet

Surency COBRA Direct Billing Implementation Worksheet

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Surency COBRA Benefits Termination Form

Surency COBRA Benefits Termination Form

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Surency Flex FSA Balance Forfeiture Form

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

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 COBRA Appeal Request Form

Surency COBRA Appeal Request Form

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

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

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

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Surency Flex Termination/Status Change Form

Surency Flex Termination/Status Change Form

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Surency Vision COBRA Billing Designation Form

Surency Vision COBRA Billing Designation Form

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Surency Vision COBRA Continuation of Group Vision Coverage Form

Surency Vision COBRA Continuation of Group Vision Coverage Form

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Surency Vision Enrollment/Change Form

Surency Vision Enrollment/Change Form

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Surency Flex HRA Renewal Form

Surency Flex HRA Renewal Form

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Surency Flex HSA Renewal Form

Surency Flex HSA Renewal Form

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Surency Flex Appeal Request Form

Surency Flex Appeal Request Form

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Surency Vision Nominate a Provider Form

Surency Vision Nominate a Provider Form

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

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

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Surency Flex Additional Benefits Card Request Form

Surency Flex Additional Benefits Card Request Form

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Surency Vision Employer Account Registration Form

Surency Vision Employer Account Registration Form

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Surency Flex Employer Account Registration Form

Surency Flex Employer Account Registration Form

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Surency Flex Benefits Card Transaction Dispute Form

Surency Flex Benefits Card Transaction Dispute Form

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Surency Flex FSA/Dependent Care FSA Renewal Form

Surency Flex FSA/Dependent Care FSA Renewal Form

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Surency Flex Direct Deposit Authorization Form

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

Surency Flex Qualified Small Employer HRA Claim Form

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Surency Flex Transit Expense Reimbursement Request Form

Surency Flex Transit Expense Reimbursement Request Form

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Surency Flex Parking Expense Reimbursement Request Form

Surency Flex Parking Expense Reimbursement Request Form

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Surency Flex HSA Transfer Form

Surency Flex HSA Transfer Form

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Surency Flex HSA Power of Attorney Form

Surency Flex HSA Power of Attorney Form

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Surency Flex HSA Information Change Notification Form

Surency Flex HSA Information Change Notification Form

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Surency Flex HSA Death Distribution Request Form

Surency Flex HSA Death Distribution Request Form

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Surency Flex HSA Contribution Form

Surency Flex HSA Contribution Form

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Surency Flex HSA Beneficiary Change/Spousal Consent Form

Surency Flex HSA Beneficiary Change/Spousal Consent Form

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Surency Flex Receipt & Substantiation Form

Surency Flex Receipt & Substantiation Form

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Surency Flex Orthodontia Claim Form

Surency Flex Orthodontia Claim Form

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Surency Flex HRA Deductible Verification Form

Surency Flex HRA Deductible Verification Form

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Surency Flex FSA/HRA Claim Form (2022)

Surency Flex FSA/HRA Claim Form (2022)

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Surency Flex FSA Deductible Verification Form

Surency Flex FSA Deductible Verification Form

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Surency Flex Capital Expense Worksheet

Surency Flex Capital Expense Worksheet

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Surency Flex Dependent Care Reimbursement Form

Surency Flex Dependent Care Reimbursement Form

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Surency Flex Dependent Care Receipt Form

Surency Flex Dependent Care Receipt Form

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Surency Flex Claims Run In Form

Surency Flex Claims Run In Form

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Surency Flex Letter of Medical Necessity Form

Surency Flex Letter of Medical Necessity Form

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Surency Vision State of Kansas Employees Out-of-Network Claim Form

Surency Vision State of Kansas Employees Out-of-Network Claim Form

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Surency Vision Out-of-Network Claim Form

Surency Vision Out-of-Network Claim Form

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