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7363 - AgencyVoucherInstructions

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September 18, 2015
To: All NYS EMS Agencies
Re: Voucher Submissions for
Training Reimbursements
To Whom It May Concern:
The New York State Office of the State Comptroller has issued a new Claim For
Payment voucher, AC3253-S, which replaces the previous form, AC92. Effective as of the date
of this letter, all Claims For Payment must be submitted using AC3253-S.
Agencies are eligible to submit to the Bureau of EMS for reimbursement for those
members and/or employees of their agency, who have become certified through a NYS BEMS
Certification Course. BEMS Policy 09-06 outlines all eligibility and submission requirements.
Please make sure you follow Policy 09-06 and any future updates to this policy.
Form AC3253-S is a fill-in-able Adobe PDF document, which can be filled out on your
computer, printed, then submitted to BEMS. We encourage you to take advantage of this
format instead of printing the form and then filling it out so the form is legible and accurate.
Following are the instructions to fill out the form:
A maximum of 6 providers can be on a single voucher. If you have more than 6 providers, you
must submit additional vouchers. Only one certification level can be submitted on one voucher.
For example, if you have 2 providers (1 EMT and 1 Paramedic) you are submitting for
reimbursement, you need to complete 2 separate vouchers.
Agency Code Your BEMS 4 digit agency code.
Vendor Name Agency name.
Address, City, State, Zip Code Agency’s official mailing address.
Vendor Identification Number
Agency’s vendor ID number as assigned by the Office of the
State Comptroller. If you have not received your vendor ID,
please go to: http://www.sfs.ny.gov/ and follow the
information for “Vendor Support”.
Invoice Number
Updated 9/18/2015
EMS – Agency Code – Course Number – Date of invoice
For Example: EMS-4519-125076-09/18/15
For CME Program: CME-4519-125000-09/18/15
Course Level
The level of the certified provider(s) you are seeking
reimbursement.
Course Number
Course number the provider attended to become certified. If
this is a CME recertification, no course number is required
for agencies.
Original, Refresher, CME
Check the box that is appropriate for the course the provider
took to become certified. Only one box may be checked.
Cert. Number Certified provider’s BEMS certification number.
Provider’s Name
Certified provider’s name you are submitting for
reimbursement.
Number Passed State Written
Exam
Total number of certified providers you are listing on this
voucher.
Reimbursement Rate
The reimbursement rate that corresponds to the course level
and if it was original, refresher or CME. Please make sure
you are using the current rate as listed in Policy 0-06.
Amount This will automatically calculate for you.
Total This will automatically calculate for you.
Discount % Leave blank.
Net This will automatically calculate for you.
Vendor’s Signature Must be signed in ink once form is printed.
Title Title of person signing this voucher.
Date Date of signature.
Name of Company Leave blank.
The AC3253-S and other information can be found on our web site at:
http://www.health.ny.gov/nysdoh/ems/main.htm. If you have questions regarding submission of
vouchers, please contact our Funding Unit at (518) 402-0996.
Sincerely,
Andrew G. Johnson, BS, EMT-P, CIC
Deputy Director for Education and Certification
Bureau of Emergency Medical Services
AC3253-S (Effective 1/12)
Vendor Name
State Zip Code
Quantity Price Amount
Total
Discount %
Vendor's Signature in Ink
Title
Net
Date Name of Company
Vendor Identification Number Vendor Location ID Vendor Address Sequence
Voucher ID Business Unit Name Bus. Unit Contract ID
Withholding Class Withholding Amount Handling Code Payee Amount
Invoice Number Invoice Date
Business Unit Department Program Fund Account
Budget Reference Project ID Activity Class Operating Unit
Product Chartfield 1 - Accumulator Chartfield 2 - Agency Use Chartfield 3 Amount
Dept Cost Center Var Yr. Dept. Statewide
TC
State
of
New York
CLAIM FOR PAYMENT
Line F/P
Liability Date From Date Subledger Optional
PeopleSoft Format Charge Lines (If Applicable)
Legacy Format Charge Lines (If Applicable)
Expenditures Liquidation
Object
Accum
Amount Orig.Agency PO/Contract
Vendor Certification
NYS Agency Information
Payment Date (MM) (DD) (YY) Merch/Inv. Rec'd Date (MM) (DD) (YY)
I certify that the above bill is just, true and correct; that no part thereof has been paid except as stated and that the balance is
actually due and owing, and that taxes from which the State is exempt are excluded.
Interest Eligible
(Y/N)
Liability Date (MM) (DD) (YY)
Invoice Number
Purchase Order No. and Date
Description of Materials/Service
Vendor Information
Vendor Identification Number
Address
City
Agency Code:
Course Level:
Original
Course Number:
Refresher
Provider's Name
Cert. Number
CME
Number Passed
State Written Exam:
Current rates can be found in the current
Funding Policy on the Bureau's web site.
Reimbursement
Rate per Student:
$000
$0
$0
$0
DOH01
3450355
28308
20809
60301
11850
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Completed 4 March 2020

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