Nys medicaid recertification form: Fill out & sign online

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Click ‘Get Form’ to open the EMT-Paramedic Recertification Form in the editor.
Begin by filling in your EMT Number and Social Security Number. Ensure all information is printed neatly in UPPER CASE letters.
Complete your personal details including Last Name, First Name, Address, City, State, and Zip Code.
Enter the Agency Code of your Participating Agency accurately.
Affirm your legal status regarding misdemeanors or felonies by checking the appropriate box and signing where indicated.
Attach copies of your current CPR and ACLS certification cards (front and back) as required.
Fill out the Skill Competency Verification section, ensuring that a Medical Director signs off on your skills.
Complete the Continuing Education sections by listing topics and hours earned. Make sure totals meet requirements.
Finally, sign and date the form along with the Sponsoring Agency Contact/Coordinator before submitting it at least 45 days prior to expiration.

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