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 Vision Maternity Benefit Self-Report Form

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

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Surency Broker Account Registration 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

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Surency Vision Nominate a Provider Form

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Surency Vision Employer Account Registration Form

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

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Surency Vision Out-of-Network Claim Form

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