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.

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
The Service Provider Application can be completed by filling out the form below or by downloading the Service Provider Application 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.