Forms and Guides

Forms and Guides

Looking for information on how to file a claim or how your FSA carryover works? Wanting to transfer funds into your NueSynergy HSA or learn about your investment options? Exploring how to establish an FSA, HSA, or HRA plan for your group?

We’ve got a form or guide for that and more. Take a look at our list of forms and guides that our participants and employer partners have found helpful.

Not finding the information that you need? Contact our team to get the answers you need.

 

Description File
Adoption Assistance Employee Guide

Employee education and FAQs for the Adoption Assistance benefit account.

PDF icon adoption_assistance_flexible_spending_account.pdf
Bank to Bank HSA Rollover Form

To move funds from a Health Savings Account with another administrator and deposit them into your NueSynergy HSA.

PDF icon nuesynergy_hsa_bank_to_bank_transfer_form.pdf
Commuter Benefits Claims Form

Commuter Benefits claim reimbursement form for eligible mass transportation and parking expenses.

PDF icon mass_transit_parking_claim_reimbursement_form.pdf
Debit Card Substantiation Guide

Step by step instructions on how to attach supporting documentation

PDF icon how_to_substantiate_your_debit_card_transaction_online.pdf
Dependent Care Eligible Expenses

List of eligible expenses for the Dependent Care FSA.

PDF icon dca_eligible_expenses.pdf
Direct Deposit Setup Form

Direct deposit setup form for FSA and HRA reimbursement.

PDF icon direct_deposit_form.pdf
Employee Commuter Benefit Guide

Employee guide to parking and transportaion pre-tax benefit accounts.

PDF icon employee_commuter_benefit_guide.pdf
Employee Dependent Care FSA Handout

Employee educational handout and account access guide for the Dependent Care FSA.

PDF icon your_dependent_care_flexible_spending_account.pdf
Employee FSA Education Handout

Employee educational handout and resource guide for the Flexible Spending Account.

Employee HSA Handout

Employee educational handout with list of eligible expenses.

PDF icon my_hsa_benefit_2017_eligible_expenses.pdf
Employee Status Change Form

Employee status change form for qualifying event election changes.

PDF icon section_125_employee_status_change_form_2016.pdf
Employer HSA Guide

An Employer's guide to Health Savings Accounts. (i.e. Contribution Limits, Eligibility, Benefits, FAQs, etc.)

PDF icon employers_hsa_guide_2017.pdf
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.

PDF icon fsa_beneficiary_designation_form.pdf
FSA Carryover Employer FAQs

A list of FAQs for employer's considering the carryover option for their Healthcare and Limited Purpose FSA plans.

PDF icon fsa_carryover_employer_faq.pdf
FSA Carryover Guide

$500 Carry-over guide for both the Healthcare and Limited Purpose Flexible Spending Accounts.

PDF icon 500_fsa_carrover_guide_healthcare_limited_purpose.pdf
FSA Carryover Participant FAQs

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

PDF icon fsa_carryover_participant_faq.pdf
FSA Claim Form

Flexible Spending Account claim reimbursement form for Healthcare, Limited Purpose, and Dependent claims.

 

PDF icon fsa_claims_reimbursement_form.pdf
HRA Claim Reimbursement Form

Health Reimbursement Arrangement claim form.

PDF icon hra_claims_reimbursement_form_participant_reimbursement.pdf
HRA Provider Pay Claim Form

For HRA plans that require claim payments be made directly to the provider.

PDF icon hra_claims_reimbursement_form_provider_pay.pdf
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.

PDF icon nuesynergy_hsa_account_maintenance.pdf
HSA Authorized Signer Form

Additional signer designation for the Health Savings Account.

PDF icon authorized_signer_form_nuesynergy.pdf
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.

PDF icon contribution_correction_form.pdf
HSA Distribution Reversal Form

To correct a distribution made in error or for an incorrect amount from your Health Savings Account.  

PDF icon hsa_distribution_reversal.pdf
HSA Eligible Expenses

A list of eligible expenses for the Health Savings Account.

PDF icon hsa_eligible_expenses.pdf
HSA Participant Guide

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

PDF icon nuesynergy_hsa_guide_2017.pdf
HSA, FSA, and HRA Comparison Guide_2017

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

PDF icon fsa_hra_hsa_comparison_chart_2017.pdf
Individual HSA Contribution Form

Complete this form if making HSA contributions via check.

PDF icon individual_contribution.pdf
Information Authorization Release Form

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

PDF icon hipaa_authorization_for_release_of_information-event_expiration.pdf
Limited Purpose FSA Educational Handout

Limited Purpose FSA employee handout with list of eligibile expenses.

PDF icon your_limited_purpose_fsa.pdf
Limited Purpose FSA Eligible Expenses

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

PDF icon limited_purpose_eligible_expenses.pdf
Member Portal Direct Deposit Setup Guide

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

PDF icon online_direct_deposit_guide.pdf
NueSynergy Benefit Card Reimbusment Purse

A debit card feature allowing for reimbursed funds to be credited to a special reimbursement purse linked to the NueSynergy benefit debit card. Improving the reimbursement process for those that normally recieve checks.

PDF icon benefit_card_reimbursement_purse.pdf
NueSynergy Benefit Debit Card FAQs

NueSynergy benefit debit card FAQs and transaction substantiation guide.

PDF icon nuesynergy_benefits_debit_card_faqs.pdf
NueSynergy Benefits Debit Card Enrollment Form

For a participant wanting to order a debit card for their self or any eligible dependents.

PDF icon debit_card_enrollment_agreement.pdf
Online Claim Guide

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

PDF icon how_to_submit_an_online_claim.pdf
Online Direct Deposit Setup Guide

Step by step instructions for setting up direct deposit online for claim reimbursement.

PDF icon online_direct_deposit_guide.pdf
Sample FSA Implementation Timeline

Sample FSA implementation timeline for both the intitial plan setup and transition from a current administrator.

PDF icon fsa_sample_timeline.pdf
Sample HRA Implemetation Timeline

Sample HRA implementation timeline for both the intitial plan setup and transition from a current administrator.

PDF icon hra_sample_timeline.pdf
Sample HSA Employee Payroll Deferral Form

Sample employee payroll deferral form for the Health Savings Account.

PDF icon sample_payroll_deferral_form.pdf
Sample HSA Implemetation Timeline

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

PDF icon hsa_sample_timeline.pdf
Sample Letter of Medical Necessity

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

PDF icon sample_letter_of_medical_necessity.pdf