Medical/Dental Reimbursement Claims

Attach copies of your medical/dental plan's explanation of benefits (EOBs) or paid receipts showing amounts not paid by those plan(s). The receipt must show the date and type of service for the expense. Canceled checks, credit card slips, or statements showing only a balance due on your account are not allowable.

Over-the-counter items: If you are claiming expenses for non-prescription drugs or medications, the cash register receipt must show both product description and price, or you must also submit product packaging showing product name and price.

Click here for a reimbursement claim form (pdf).

Dependent Care Expenses Claims

You must provide the name, address and Social Security number or Employer Identification (EIN) number of each dependent care provider.

Click here for a reimbursement claim form (pdf).

Healthcare Reimbursement Arrangement (HRA) Claims

Your Health Reimbursement Arrangement (HRA) Plan may be limited by the types of healthcare expenses that may be reimbursed to you.  Please read the Summary Plan Description for your HRA Plan for a list of eligible expenses.

Click here for a reimbursement claim form (doc).

Where To Send A Claim

Mail: File claims by mailing the completed claim form together with required receipts and EOBs to:

Employee Choice Plan
MVP Select Care
620 Erie Blvd. West, #200
Syracuse, NY 13204

Fax: Claims may filed by faxing the completed claim form and required EOBs or receipts to:

Employee Choice Plan
MVP Select Care
(315) 234-6146

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