Please complete the Service Provider Application below.
Complete all applicable fields. Write “N/A” for all fields that do not apply. If you have any questions, please call 315-477-9820.
The Service Provider Application can also be completed by:
- downloading the Service Provider Application (pdf), completing it in its entirety and either:
- email to: firstname.lastname@example.org
- fax to: 315.671.5129
- mail to:
Nascentia Health Options
Attn: Provider Relations Department
1050 West Genesee Street
Syracuse, NY 13204-221