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Claim For Payment Submission Portal
This submission portal is to be used for EMS Agencies or EMS Course Sponsors to submit reimbursement vouchers for original courses or refresher programs.
AC3253-S Claim For Payment Form
Course Sponsor, EMS Agency, National Registry or CME Voucher
Course Sponsor
EMS Agency
National Registry Proctor
CME Voucher
Submitting Individual Information
Full Name
Company
Email
Phone
Is this submission for a Course, PSE or Both?
Course
PSE
Both
Claim For Payment
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
PSE Score Sheet
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Written Exam Results
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Claim For Payment
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Proof of EMS Certification
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Proof of Payment
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Paramedic Letter
Yes
No
Is this submission the result of a Paramedic Letter sent to EMS agencies.
Is this submission the result of a Paramedic Letter sent to EMS agencies?
Yes
No
Claim For Payment
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
CME Reimbursement submissions via this portal are only for those CME recertifications that were not vouchered along with the submission package on the CME Portal.
Submission ID (SID)
?
Vendor ID
Vendor Name
Invoice Number
Invoice Date
Obligation Date
Invoice Amount
Description
Voucher Attachment
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
CAPTCHA
Submit