Please complete the Recredentialing Form 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.

Managed Long-Term Care Recredentialing Form
  • General Information
  • Parent Company Name and Contact Information
  • Location Information
  • Recredentialing Forms
  • Provider Compliance Certification and Attestation
  • Recredentialing Attestation and Release Form and Certification / Affirmation of Accuracy and Completeness
  • Review Application
The Recredentialing Form can be completed by filling out the form below or by downloading the Recredentialing Update form (pdf), filling it out in its entirety and either:

    • Email to: providerrelations@477home.org
    • Fax to: (315) 671-5129
    • Mail to:
      Nascentia Health Options
      Attn: Provider Relations Department
      1050 West Genesee Street
      Syracuse, NY 13204-221

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.