New Service Provider Application

For Adult Day Care (ADHC, SADC), Audiologists/Hearing Aids, Consumer-Directed Personal Aid (FI), Home and Safety Modification, Licensed Home Care Services Agency (LHCSA), and Meals Provider

Complete the New Service Provider Application using the online form below, or download and complete the New Service Provider Application PDF.

Completed applications may be submitted by:

Questions: Call (315) 477-9280

Managed Long-Term Care Service Provider Application
  • General Information
  • Parent Company Name and Contact Information
  • Location Information
  • Service Provider Applications
  • Provider Compliance Certification and Attestation
  • Credentialing Attestation and Release Form and Certification / Affirmation of Accuracy and Completeness
    • Review Application

    General Information

    (include area code)
    (include area code)
    (include area code)
    (include area code)
    Medicare Certification:
    (required for FI and Home Care providers)

    If your facility has more than 1 NPI#, please list the NPI# and the facility name below.

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    Last Updated on August 11, 2026