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Submitting For Reimbursement

Submitting a Reimbursement Request is Simple!


  1. Visit our “Forms” section on our websites main menu ( to retrieve a Flexible Spending/Medical Reimbursement Voucher.
  • Fill out Part I: Employee Information
  • Fill out Part II, Part III, and/or Part IV – depending on which section you are requesting reimbursement for.
  • Sign and Date the bottom of the Reimbursement Voucher

*If you are filling out an ONLINE Reimbursement Voucher, it is NOT necessary to submit a paper copy*


  1. Submit Necessary Documentation WITH your Reimbursement Voucher:


If You’re Covered By Insurance

Submit your claim to the insurance carrier first and obtain an Explanation of Benefits (EOB)

  1. Request an EOB from your insurance showing the amount you paid out-of-pocket
  2. Submit the EOB with your Reimbursement Voucher for reimbursement

    (Log-in to your insurance carriers website to obtain your EOBs)


If You’re NOT Covered By Insurance

Submit an itemized statement CLEARLY stating ALL of the following:

  1. Patients Name
  2. Dollar amount paid out-of-pocket
  3. Date of Service provided (Date of payment is NOT eligible)
  4. Provider name/address
  5. Services Rendered to the Patient (Exam, x-ray, crown, hospital visit, etc.)

( You may request an itemized statement from your Health Care Provider)


Dependent Day Care Expenses

Include the following information:

  1. Dependent Care Providers name/address
  2. Date(s) the child/elder was cared for
  3. Name of the dependent being cared for
  4. Type of service being rendered
  5. Amount paid for the services rendered

(Be sure to have submitted your Dependent Care Registration Statement PRIOR to submitting for Dependent Care Expense Reimbursement)


Prescriptions, Over the Counter Drugs, and Medicines

Include the following:


  1. Pharmacy script/mail order statement showing Patient Name, Name of drug/Rx, Date Filled, Dollar Amount, OR, **
  2. Printout of prescription(s) from pharmacy

**Note: A receipt without the prescription name is NOT eligible


  1. See our “Eligible Expenses” Form for the “Not Eligible without a Rx” list of Over-The-Counter Medicines.
  2. If an item is in the “Not Eligible without a Rx” list, the receipt MUST include cash register receipt showing merchant name, date, product description, dollar amount, and written prescription from the patient’s physician.



Include the following:

  1. Payment invoice with monthly appointments listed; or,
  2. Itemized statement and payment receipt if claiming one upfront payment


According to the IRS, the following are unacceptable documentation:

- Cancelled Checks

- Credit Card Receipts

- Statements that say “balance forward”, “previous balance due” or “paid on account”

- Statements for services not yet rendered

- Pre-treatment estimates of services to be provided in the future

- Statements that do not include the date of service

- Statements that do not include description of service

- Statements that do not include the providers name, patient’s name, and dollar amount owed.


          3. Reimbursement Vouchers and Necessary Documentation can be submitted by e-mail, fax, or mail.

  • To submit by e-mail, send ALL documentation and Reimbursement Vouchers to

** You will receive an e-mail confirmation from a Customer Service Representative once your e-mail has been received and sent to our Claims Department. If you have not received an e-mail after 24 hours, your attachments may be too large and you will need to be resend in multiple e-mails.

  • To submit by fax, send ALL documentation and Reimbursement Vouchers to 1-585-248-2488.

    (Please do not mail your claim if you fax it)
  • To submit by mail, send ALL documentation and Reimbursement Vouchers to:

M.A. Services

P.O. Box 587

Pittsford, NY 14534-0587


Please notify M.A. Services in writing if you have a change in address

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