Managed Long-Term Care Service Provider 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

Please complete the form in its entirety. Questions: 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

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.