Surency Forms
Whether you have a Surency Vision plan or Surency Flex plan, find applicable forms below to help manage your account.
VIEW BY CATEGORY
Surency Flex HSA Election Change Form
Download Form
Surency Flex HSA Information Authorization Form
Download Form
Surency Flex HSA Distribution-HRA Claim Form
Download Form
Surency COBRA Appeal Request Form
Download Form
Surency COBRA Authorization for Disclosure of Protected Health Information (HIPAA) Form
Download Form
Surency Vision Authorization for Disclosure of Protected Health Information (HIPAA) Form
Download Form
Surency Flex Termination/Status Change Form
Download Form
Surency Vision COBRA Billing Designation Form
Download Form
Surency Vision COBRA Continuation of Group Vision Coverage Form
Download Form
Surency Vision Enrollment/Change Form
Download Form
Surency Flex HRA Renewal Form
Download Form
Surency Flex HSA Renewal Form
Download Form
Surency Flex Appeal Request Form
Download Form
Surency Vision Nominate a Provider Form
Download Form
Surency Flex Authorization for Disclosure of Protected Health Information (HIPAA) Form
Download Form
Surency Flex Additional Benefits Card Request Form
Download Form
Surency Vision Employer Account Registration Form
Download Form
Surency Flex Employer Account Registration Form
Download Form
Surency Flex Benefits Card Transaction Dispute Form
Download Form
Surency Flex FSA/Dependent Care FSA Renewal Form
Download Form
Surency Flex Direct Deposit Authorization Form
Download Form
Surency Flex HSA Distribution Request Form
Download Form
Surency Flex Qualified Small Employer HRA Claim Form
Download Form
Surency Flex Transit Expense Reimbursement Request Form
Download Form
Surency Flex Parking Expense Reimbursement Request Form
Download Form
Surency Flex HSA Transfer Form
Download Form
Surency Flex HSA Power of Attorney Form
Download Form
Surency Flex HSA Information Change Notification Form
Download Form
Surency Flex HSA Direct Deposit Enrollment/Change Form
Download Form
Surency Flex HSA Death Distribution Request Form
Download Form
Surency Flex HSA Contribution Form
Download Form
Surency Flex HSA Beneficiary Change/Spousal Consent Form
Download Form
Surency Flex Receipt & Substantiation Form
Download Form
Surency Flex Orthodontia Claim Form
Download Form
Surency Flex HRA Deductible Verification Form
Download Form
Surency Flex FSA/HRA Claim Form
Download Form
Surency Flex FSA Deductible Verification Form
Download Form
Surency Flex Capital Expense Worksheet
Download Form
Surency Flex Dependent Care Reimbursement Form
Download Form
Surency Flex Dependent Care Receipt Form
Download Form
Claims Run In
Download Form
Surency Flex Letter of Medical Necessity Form
Download Form
Surency Vision State of Kansas Employees Out-of-Network Claim Form
Download Form