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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COBRA Continuation of Group Vision Coverage
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Vision Enrollment/Change
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HRA Renewal
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HSA Renewal
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Appeals Request
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Nominate a Provider
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Authorization for Disclosure of Protected Health Information (HIPAA)
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Additional Benefits Card Request
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Vision Employer Account Registration
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Surency Flex Employer Account Registration
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Benefits Card Transaction Dispute
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FSA / Dependent Care FSA Renewal
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Direct Deposit Authorization
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Distribution Request
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Qualified Small Employer HRA Claim
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Transit Expense Reimbursement Request
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Parking Expense Reimbursement Request
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HSA Transfer
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Power of Attorney
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HSA Information Change Notification
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Direct Deposit Enrollment/Change
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Death Distribution Request
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HSA Contribution
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Beneficiary Change/Spousal Consent
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Receipt & Substantiation
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Orthodontia Claim
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Deductible Verification
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FSA/HRA Claim
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Deductible Verification
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Capital Expense Worksheet
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Dependent Care Reimbursement
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Dependent Care Receipt
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Claims Run In
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Letter of Medical Necessity
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State of Kansas Employees Out-of-Network Claim Form
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