Fillable September 18, 2015 To: All NYS EMS Course (New York State)

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September 18, 2015 To: All NYS EMS Course (New York State)

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September 18, 2015
To: All NYS EMS Course Sponsors
Re: Voucher Submissions for 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.
Course Sponsors are eligible to submit to the Bureau of EMS for reimbursement under
the guidelines of BEMS Policy 09-06. 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 one course can be on a single voucher. If you have more than one course, you
must submit additional vouchers. A copy of the examination results from our testing contractor,
must accompany the voucher with all names highlighted for whom you are seeking
reimbursement. A copy of the Final PSE Summary Sheet must also be included with the
appropriate names highlighted.
Sponsor Code Your BEMS 4 digit Course Sponsor code.
Vendor Name Course Sponsor’s name BEMS has on-file.
Address, City, State, Zip Code Course Sponsor’s official mailing address.
Vendor Identification Number Course Sponsor’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 09/18/15
EMS-SponsorCode-Course#-InvoiceDate
For example: EMS-02016-125000-09/18/15
Course Level The level of the course you are seeking reimbursement. i.e.
CFR, EMT, Intermediate, Critical Care, or Paramedic
Course Number Course number you were assigned by BEMS.
Original, Refresher, CME Check the box that is appropriate for the course the provider
took to become certified. Only one box may be checked.
Course Start Date The date the course was approved to begin.
Written Exam Date The date of the State Written Certification Exam that was
scheduled by BEMS.
Number Passed State Written
Exam
Total number of students who passed the State Written
Certification Exam and who are listed on the exam results
documentation, which must be submitted with this vouche
r
.
Reimbursement Rate per
Student
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.
Number of Students for the State
Final Practical Skills Exam.
The total number of students who took the Final PSE.
Reimbursement Rate per
Student
The reimbursement rate that corresponds to the course level
and if it was original, refresher or CME for the Final PSE.
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 after the 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, AEMT-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
Unit
Vendor Information
Vendor Identification Number
Address
City
Sponsor Code:
Course Level:
Original
Refresher
Course Number:
CME
Course Start Date:
Number Passed
State Written Exam:
Written Exam Date:
Number of Students
that Took the State
Final Practical Skills
Exam:
Reimbursement
Rate per Student:
Reimbursement
Rate per Student:
$000
$000
$0
$0
0.00
0.00
DOH01
3450355
28308
20809
60301
11850
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September 18, 2015 To: All NYS EMS Course (New York State)

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Completed 17 November 2021

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