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 2019_adoption_assistance_fsa_.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 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 commuter_benefits_claims_form.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
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.

PDF icon set_up_eclaims_manager.pdf
Employee Commuter Benefit Guide

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

PDF icon commuter_benefit_guide.pdf
Employee Dependent Care FSA Handout

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

PDF icon 2019_your_dependent_care_fsa.pdf
Employee FSA Handout

Employee educational handout with list of eligible expenses.

PDF icon 2019-nuesynergy-your-fsa.pdf
Employee HSA Handout

Employee educational handout with list of eligible expenses.

PDF icon 2019-nuesynergy-my-hsa-benefit.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.pdf
FSA Carryover Guide

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

PDF icon fsa_carryover_guide.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 2019_fsa_carryover_participant_faq.pdf
FSA Claim Form

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

 

PDF icon fsa_claim_reimbursement_form-fillable.pdf
HRA Claim Reimbursement Form

Health Reimbursement Arrangement claim form.

PDF icon hra_participant_claim_form.pdf
HRA Provider Pay Claim Form

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

PDF icon hra_provider_pay_form.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 hsa_account_maintenance.pdf
HSA Authorized Signer Form

Additional signer designation for the Health Savings Account.

PDF icon authorized_signer_form.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 2019_hsa_welcome_kit-update.pdf
HSA-HRA Administrator FAQ PDF icon sehp_new_hsa-hra_administrator_faq-employee.pdf
HSA_HRA_Administrator_FAQ PDF icon sehp_new_hsa-hra_administrator_faq-employee_final.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 benefit account.

PDF icon hipaa_release.pdf
Limited Purpose FSA Eligible Expenses

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

PDF icon limited_purpose.pdf
Member Portal Direct Deposit Setup Guide

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

PDF icon direct_deposit_guide.pdf
NueSynergy Benefit Debit Card FAQs

NueSynergy benefit debit card FAQs and transaction substantiation guide.

PDF icon benefits_debit_card.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_agreement.pdf
Online Claim Guide

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

PDF icon file_an_online_claim.pdf
Online Direct Deposit Setup Guide

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

PDF icon direct_deposit_guide.pdf
Publication 502

Medical and dental expenses.

PDF icon p502-2018.pdf
Publication 969

IRS guidelines for HSAs and other tax favored plans.

PDF icon publication_969_2018_.pdf
Sample Letter of Medical Necessity

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

PDF icon sample_letter_medical_nec.pdf