Forms and Guides
Downloadable for your convenience.
Adoption Assistance Employee Guide
Employee education and FAQs for the Adoption Assistance benefit account.
Bank to Bank HSA Rollover Form
To move funds from a Health Savings Account with another administrator and deposit them into your NueSynergy HSA.
Combined Billing: A Brief Overview
This flyer/infographic provides a brief overview of Combined Billing and how it works.
Commuter Benefits Claims Form
Commuter Benefits claim reimbursement form for eligible mass transportation and parking expenses.
Dependent Care Eligible Expenses
List of eligible expenses for the Dependent Care FSA.
Direct Deposit Setup Form
Direct deposit setup form for FSA and HRA reimbursement.
eClaims Manager Setup
eClaims Manager provides access to an employee’s claims data or explanation of benefits (EOBs), allowing increased auto-substantiation of debit card claims and easier electronic manual claim submission
Employee Commuter Benefit Guide
Employee guide to parking and transportaion pre-tax benefit accounts.
Employee Dependent Care FSA Handout
Employee educational handout and account access guide for the Dependent Care FSA.
Employee FSA Handout
Employee educational handout with list of eligible expenses.
Employee HSA Handout
Employee educational handout with list of eligible expenses.
Employer HSA Guide
An Employer’s guide to Health Savings Accounts. (i.e. Contribution Limits, Eligibility, Benefits, FAQs, etc.)
FSA Beneficiary Designation Form
Beneficiary Designation form for the Flexible Spending Account benefit to designate the individual/s that may have certain obligations and responsibilities to file claims and seek reimbursement under the terms of the plan in the event of your death.
FSA Carryover Employer FAQs
A list of FAQs for employer’s considering the carryover option for their Healthcare and Limited Purpose FSA plans.
FSA Carryover Guide
$500 Carry-over guide for both the Healthcare and Limited Purpose Flexible Spending Accounts.
FSA Carryover Participant FAQs
A list of FAQs for participants who have the carryover feature for their Healthcare or Limited Purpose FSA plan.
FSA Claim Form
Flexible Spending Account claim reimbursement form for Healthcare, Limited Purpose, and Dependent claims.
FSA Claim Form (Spanish)
Flexible Spending Account claim reimbursement form (Spanish) for Healthcare, Limited Purpose, and Dependent claims.
HRA Claim Reimbursement Form
Health Reimbursement Arrangement claim form.
HRA Provider Pay Claim Form
For HRA plans that require claim payments be made directly to the provider.
HSA Account Maintenance Form
To update your Health Savings Account (HSA) due to a name, phone or address change. Also update, add, or revoke an additonal signer to your HSA.
HSA Authorized Signer Form
Additional signer designation for the Health Savings Account.
HSA Contribution Correction Form
This form allows you to correct a contribution made in error, contributions made while not being eligible or a contribution over the allowed maximum.
HSA Distribution Reversal Form
To correct a distribution made in error or for an incorrect amount from your Health Savings Account.
HSA Eligible Expenses
A list of eligible expenses for the Health Savings Account.
HSA Participant Guide
A participant overview of the Health Savings Account (i.e. contribution limits, eligbile expenses, tax benefits, etc.)
HSA, FSA, and HRA Comparison Guide 2019
A side-by-side comparison of the Health Savings Account, Flexible Spending Account, and Health Reimbursement Arrangement.
Individual HSA Contribution Form
Complete this form if making HSA contributions via check.
Information Authorization Release Form
Release form enabling you to designate individuals that you authorize NueSynergy to release information to related to your benefit account.
Limited Purpose FSA Eligible Expenses
List of eligible expenses for the Limited Purpose Flexible Spending Account.
Member Portal Direct Deposit Setup Guide
Guide to setting up direct deposit for reimbursement through the Member Portal.
NueSynergy Benefit Debit Card FAQs
NueSynergy benefit debit card FAQs and transaction substantiation guide.
NueSynergy Benefits Debit Card Enrollment Form
For a participant wanting to order a debit card for their self or any eligible dependents.
Online Claim Guide
This guide provides you with step by step instructions on how to submit a claim online.
Publication 502
Medical and dental expenses.
Publication 969
IRS guidelines for HSAs and other tax favored plans.
Sample FSA Implementation Timeline
Sample FSA implementation timeline for both the intitial plan setup and transition from a current administrator.
Sample HRA Implementation Timeline
Sample employee payroll deferral form for the Health Savings Account.
