Forms and Guides

Downloadable for your convenience.

Adoption Assistance Employee Guide

Employee education and FAQs for the Adoption Assistance benefit account.

Best of Both Worlds: NueSynergy Products & Services

CARES Act Update

COBRA Composite and Member Level Rate Table

COBRA Composite Table

COBRA Member-Level Rate Table

COBRAcare+ Informative

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.

Commuter Benefits Employee Guide

Dependent Care Eligible Expenses

List of eligible expenses for a Dependent Care FSA.

Dependent Care FSA Employee Guide

Direct Deposit Setup Form

Direct deposit setup form for FSA and HRA reimbursement.

Discrimination Testing Form

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

Eligible Reimbursements and Travel Expenses for Abortion

This form details where women can find appropriate abortion care; such as employee benefits, travel reimbursements, travel expenses and more.

Employee Care Card Breakdown

Employee Commuter Benefit Guide

Employee guide to parking and transportation 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 FSA eligible expenses.

Flexible Spending Account Limits (2024 + 2025)

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 Participant FAQs

A list of FAQs for participants who have the carryover feature for their Healthcare or Limited Purpose FSA plan.

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.

Health Care FSA Employee Guide

A participant overview of the Health Care FSA (i.e. contribution limits, eligbile expenses, tax benefits, etc.)

How To File A Claim Guide

This guide provides you step-by-step instructions on how to submit a claim online.

How to Substantiate a Debit Card Transaction

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 Authorized User Form

HSA Benefit Contribution Limits (2024+2025)

HSA Eligible Expenses

A list of eligible expenses for a Health Savings Account.

HSA, FSA, and HRA Comparison Guide

A side-by-side comparison of the Health Savings Account, Flexible Spending Account, and Health Reimbursement Arrangement.

HSA, HDHP, and EBHRA IRS Limits (2024+2025)

Information Authorization Release Form

Release form enabling you to designate individuals that you authorize NueSynergy to release information to related to your benefit account.

IRS Publication 502

Check out the latest IRS 502 Publication document

IRS Publication 969

IRS guidelines for HSAs and other tax favored plans.

Letter of Medical Necessity

An example of the information needed within a Letter of Medical Necessity.

Limited Purpose FSA Eligible Expenses

List of eligible expenses for a Limited Purpose Flexible Spending Account.

Limited Purpose FSA Employee Guide

Mileage Reimbursement Worksheet

NueSynergy Benefit Debit Card FAQs

NueSynergy benefit debit card FAQs and transaction substantiation guide.

NueSynergy Benefits Debit Card Enrollment Form

Fill out this form if you are a participant wanting to order a debit card for yourself or any eligible dependent(s).

NueSynergy Lifestyle Spending Account

Online Direct Deposit Setup Guide

Guide to setting up direct deposit for reimbursement through the Member Portal.

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 HRA implementation timeline for both the initial account setup and transition from a current administrator.

Sample HSA Implementation Timeline

Sample HSA implementation timeline for both the initial account setup and transition from a current administrator.

Sample Summary of Benefits

Spanish HSA Benefit Contribution Limits (2024+2025)

SpouseSaver Incentive Account Informative

SpouseSaver Incentive Account: Enrollment Process

“I am appreciative of how pleasant my customer service representative was and her genuine kindness while assisting me. She is an excellent representative for NueSynergy.” – Dr. Lucinda Whitney