Ac3253 s 2012 form-2025

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The document outlines the new Claim For Payment voucher AC3253-S for training reimbursements for New York State EMS agencies, replacing the previous form AC92. It details eligibility requirements, submission instructions, and the process for filling out the form to ensure accurate reimbursement claims for certified providers. Agencies are encouraged to use the fillable PDF format and must adhere to BEMS Policy 09-06.

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Click ‘Get Form’ to open the AC3253-S in the editor.
Enter your BEMS 4-digit agency code in the 'Agency Code' field.
Fill in your agency name under 'Vendor Name' and provide the official mailing address, including city, state, and zip code.
Input your agency's vendor identification number as assigned by the Office of the State Comptroller.
Leave the 'Invoice Number' field blank as instructed.
Select the appropriate course level (Original, Refresher, CME) by checking one box only.
Provide the certified provider’s BEMS certification number and their name for reimbursement.
Indicate the total number of providers listed on this voucher in 'Number Passed State Written Exam'.
Ensure that you are using the current reimbursement rate as per Policy 09-06 for accurate calculations.
Print the completed form and sign it in ink where indicated. Fill in your title and date of signature before submission.

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