| Nascentia Health Options

Service Provider Application

Please complete the Service Provider Application by:

completing the online form below in its entirety
downloading the Service Provider Application (pdf), completing it in its entirety and ether:
- 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 13204-2215

If a field/section does not apply, write “N/A”.

Questions: Call 315.477.9820

General Information:

Name: (required)

Email: (required)

Street Address: (required)

City: (required)

State: (required)

Zip code: (required)

County: (required)

Phone (include area code): (required)
( )

Fax (include area code): (required)
( )

Billing Address: (required)

Billing City: (required)

Billing State: (required)

Billing Zip code: (required)

Billing County: (required)

Billing Phone (include area code): (required)
( )

Fax for Authorizations (include area code): (required)
( )

Tax ID (EIN) #: (required)

Medicaid Provider Number:

Medicare Certification:

Yes No N/A

Medicare Provider Number:

NPI #:

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

2.
NPI #:

NPI Facility Name:

3.
NPI #:

NPI Facility Name:

4.
NPI #:

NPI Facility Name:

License / Facility Operating Certificate #:

Parent Company Name and Contact Information (if applicable):

Parent Company:

Parent Company Street Address:

Parent Company City:

Parent Company State:

Parent Company Zip code:

Primary Contact Person:

Primary Contact Person Title:

Primary Contact Person Phone (include area code):
( )

Primary Contact Person Email:

Location Information

Please indicate counties serviced by main address location: (required)

Address and Phone Number of Branch or Satellite Offices (with counties serviced):

1)

2)

3)

4)

5)

Operating Hours: Please list hours (a.m. and p.m.):

Monday: (required)

Tuesday: (required)

Wednesday: (required)

Thursday: (required)

Friday: (required)

Saturday: (required)

Sunday: (required)

Contact Information (Include Name, Title, Phone Number and Email):

Compliance: (required)

Contracts: (required)

Credentialing: (required)

Scheduling: (required)

Billing: (required)

If your facility uses a third-party billing agency, please provide the legal name and address below:

Billing Format and Forms Used (i.e. UB-92, HCFA-1500, etc):

Please check all items applicable to your location:

Public Transportation Accessibility
Wheelchair Accessible
Foreign Languages Spoken (If so, which languages?)
American Sign Language
Network Hearing System (TDD)
Elevator
Vision Accessible
Other
(If so, please list)

****THE FULLY EXECUTED CONTRACT WILL BE MAILED BACK TO THE PERSON WHO SIGNED IT. IF YOU WISH FOR IT TO BE MAILED TO A DIFFERENT PERSON/ADDRESS PLEASE LIST BELOW****

Name:

Street Address:

City:

State: (required)

Zip code:

Service Provider Applications:

Please select what type of service provider(s) you are applying for:

Adult Day Care
Certified Home Care Agency (CHHA) / Licensed Home Care Services Agency (LHCSA)
Consumer-Directed Personal Aid (FI)
Durable Medical Equipment / Personal Emergency Response System
Home and Safety Modification
Licensed / Certified Professional Services
Meals Provider
Skilled Nursing Facility (SNF)
Transportation Provider

Complete the required sections for each service provider you are applying for. After completing the General Information, Location Information and the necessary Service Provider Applications REMEMBER TO COMPLETE the Attestation, Credentialing Attestation and Release Form and Certification / Affirmation of Accuracy and Completeness.

Adult Day Care:

Please attach the following documents:
Acceptable file types are: pdf, jpg, jeg, png, gif, doc, docx

Business Associates Agreement (BAA) (Social adult day only):
- Nascentia will send for review and signature along with finalized contract.

EIN, Medicaid Provider Number & NPI number (provide information in the General Information section of this form)

W-9 with legal name and remit address:

Proof of OMIG Certification (Social adult day only):

Provider Compliance Certification (provide information in the Provider Compliance Certification below) – applicable only to adult medical day care providers
- Certification of a Provider Compliance Program is required. By signing the Certification Statement for Provider Billing Medicaid, you (or the entity) certify that you (or the entity) have adopted and implemented an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title 18 of the New York Code, Rules and Regulations Part 521. For more information on the Provider compliance Program, please go to the program website at https://omig.ny.gov/compliance/compliance.
- If a 2021 certification is not yet due, please provide a copy of 2019 SSL Certification.

Proof of adequate insurance coverage - General Liability and Professional Liability (ACORD Form with Nascentia Health Options, 1050 West Genesee St, Syracuse, NY 13204, listed in the certificate holder box; minimum requirement of 1 million per occurrence and 3 million aggregate, or umbrella coverage):

Note:

Provider Compliance Certification not applicable to Adult Social Day Care providers
Before contract may be executed, an in-person site inspection visit must be completed. Your regional Provider Relations Representative will request to schedule one upon receipt of all necessary credentialing documentation listed above.

Adult Day Care Services Offered (Check all that apply):

Adult Medical Day Care – Full Day
Adult Medical Day Care – Half Day
Adult Social Day Care – Full Day
Adult Social Day Care – Half Day
Meals Included
Day Care Transportation – Taxi
Day Care Transportation – Wheelchair

Certified Home Care Agency (CHHA) / Licensed Home Care Services Agency (LHCSA):

Please attach the following documents:
Acceptable file types are: pdf, jpg, jeg, png, gif, doc, docx

Valid state license(s) or operating certificate(s):

JCAHO accreditation report (if applicable):

Most recent NYSDOH State Survey & Plan of Correction:

EIN, Medicaid Provider Number & NPI number (provide information in the General Information section of this form)

W-9 with legal name and remit address:

Copy of patient satisfaction survey:

FLSA Attestation Form (complete form(s) below and sign)

Provider Compliance Certification (provide information in the Provider Compliance Certification below)
- Certification of a Provider Compliance Program is required. By signing the Certification Statement for Provider Billing Medicaid, you (or the entity) certify that you (or the entity) have adopted and implemented an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title 18 of the New York Code, Rules and Regulations Part 521. For more information on the Provider compliance Program, please go to the program website at https://omig.ny.gov/compliance/compliance.
- If a 2021 certification is not yet due, please provide a copy of 2019 SSL Certification.

Proof of adequate insurance coverage - General Liability, Professional Liability and Transportation (ACORD Form with Nascentia Health Options, 1050 West Genesee St, Syracuse, NY 13204, listed in the certificate holder box; minimum requirement of 1 million per occurrence and 3 million aggregate, or umbrella coverage):

JCAHO Accreditation:

Yes
No
N/A

CARF Accreditation:

Yes
No
N/A

Certified Home Health Care Agency Services offered (Check all that apply):

Home Health Aide
Housekeeping (Personal Care Aide, Level I)
Personal Care Aide, Level II
Medical Social Work
Medication Dispensing Services
Nutritional Counseling
Nursing, in home (LPN, RN)
Occupational Therapy
Physical Therapy
Speech Therapy
Personal Emergency Response Systems (PERS) – Landline
Personal Emergency Response Systems (PERS) – Cellular
Personal Emergency Response Systems (PERS) – GPS
Personal Emergency Response Systems (PERS) – Fall Detection
PRI & Screen Assessment Services
Private Duty Nursing, LPN
Private Duty Nursing, RN
Respiratory Therapy
Telehealth Services
UAS Assessment Services
Wound Care
Other Services
If selected, list “Other Services”:

Licensed Home Care Agency Services offered (Check all that apply):

NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS - CERTIFIED HOME HEALTH AGENCY

Attestation of Compliance with Fair Labor Standards Act (FLSA) Funding

I hereby certify that funding for all Medicaid home care services provided by my organization in accordance with the Department’s April 2017 Dear Colleague Letter on FLSA Implementation, will be passed through to the home care worker, in its entirety. I further certify that I will maintain all records necessary to verify compliance with this directive (including required licensed home care service agency attestations and information) for a period of no less than ten years from the end of the applicable calendar year; and that such records will be subject to audit by the Department and/or its agents for possible retroactive recoupment of Medicaid payments for services that are determined to be in less than full compliance.

In addition, I will provide the managed care organization, if applicable, and/or the Department (when applicable) with all information to verify my compliance with the terms of this directive (including this attestation) and that such information shall be made available to the Department upon request.

Check the appropriate box:

Fee-For-Service
Managed Care

Name of CHHA:

Operating Certificate #:

Date:

Signature: (required*)
Please draw your signature in the space below:

*If you are unable to sign the form electronically, please download the signature page here, sign, and either fax to (315) 671-5129 or email to providerrelations@477home.org.

Printed Name:

Title:

Please note that in accordance with Parts 86-1.2 of Title 10 of the Commissioner’s Administrative Rules and Regulation, only the following individuals may sign this attestation:

Proprietary Sponsorship – Operator/ Owner
Voluntary Sponsorship – Officer (President, Vice President, Secretary or Treasurer), Chief Executive officer, Chief Financial Officer or Chairperson, Public Sponsorship – Public Official Responsible for the Operation of the Facility

Please note that the Department reserves the right to request additional information in the future to ensure compliance with terms of the April 2017 Dear Colleague Letter on FLSA Implementation.

NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS - LICENSED HOME CARE AGENCY

Attestation of Compliance with Fair Labor Standards Act (FLSA) Funding

I hereby certify that funding for all Medicaid home care services provided by my organization in accordance with the Department’s April 2017 Dear Colleague Letter on FLSA Implementation, will be passed through to the home care worker, in its entirety. I further certify that I will maintain all records necessary to verify compliance with this directive (including this attestation and related information) for a period of no less than ten years from the end of the applicable calendar year; and that such records will be subject to audit by the Department and/or its agents for possible retroactive recoupment of Medicaid payments for services that are determined to be in less than full compliance.

Check the appropriate box:

Fee-For-Service
Managed Care

Name of LHCSA:

License #:

Date:

Signature: (required*)
Please draw your signature in the space below:

*If you are unable to sign the form electronically, please download the signature page here, sign, and either fax to (315) 671-5129 or email to providerrelations@477home.org.

Printed Name:

Title:

Please note that in accordance with Parts 86-1.2 of Title 10 of the Commissioner’s Administrative Rules and Regulation, only the following individuals may sign this attestation:

Proprietary Sponsorship – Operator/ Owner
Voluntary Sponsorship – Officer (President, Vice President, Secretary or Treasurer), Chief Executive Officer, Chief Financial Officer or any Member of the Board of Directors, Public Sponsorship – Public Official Responsible for the Operation of the Facility

Please note that the Department reserves the right to request additional information in the future to ensure compliance with terms of the April 2017 Dear Colleague Letter on FLSA Implementation.

Consumer-Directed Personal Aid (FI):

Please attach the following documents:
Acceptable file types are: pdf, jpg, jeg, png, gif, doc, docx

EIN, Medicaid Provider Number & NPI number (provide information in the General Information section of this form)

W-9 with legal name and remit address:

FLSA Attestation From (complete form below and sign)

Provider Compliance Certification (provide information in the Provider Compliance Certification below)
- Certification of a Provider Compliance Program is required. By signing the Certification Statement for Provider Billing Medicaid, you (or the entity) certify that you (or the entity) have adopted and implemented an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title 18 of the New York Code, Rules and Regulations Part 521. For more information on the Provider compliance Program, please go to the program website at https://omig.ny.gov/compliance/compliance.
- If a 2021 certification is not yet due, please provide a copy of 2019 SSL Certification.

Proof of adequate insurance coverage - General Liability and Professional Liability (ACORD Form with Nascentia Health Options, 1050 West Genesee St, Syracuse, NY 13204, listed in the certificate holder box; minimum requirement of 1 million per occurrence and 3 million aggregate, or umbrella coverage):

NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS - CONSUMER DIRECTED FISCAL INTERMEDIARY

Attestation of Compliance with Fair Labor Standards Act (FLSA) Funding

I hereby attest that funding for all Medicaid consumer directed personal assistance services provided by my organization in accordance with the Department’s April 2017 Dear Colleague Letter on FLSA Implementation, will be passed through to the consumer directed worker, in its entirety. I further certify that I will maintain all records necessary to verify compliance with this directive (including this attestation and related information) for a period of no less than ten years from the end of the applicable calendar year; and that such records will be subject to audit by the Department and/or its agents for possible retroactive recoupment of Medicaid payments for services that are determined to be in less than full compliance.

Check the appropriate box:

Fee-For-Service
Managed Care

Name of FI:

MMIS No. (Medicaid ID):

Date:

Signature (required*):
Please draw your signature in the space below:

*If you are unable to sign the form electronically, please download the signature page here, sign, and either fax to (315) 671-5129 or email to providerrelations@477home.org.

Printed Name:

Title:

The following individuals may sign this attestation:

Proprietary Sponsorship – Operator/ Owner
Voluntary Sponsorship – Officer (President, Vice President, Secretary or Treasurer), Chief Executive Officer, Chief Financial Officer or any Member of the Board of Directors

Please note that the Department reserves the right to request additional information in the future to ensure compliance with terms of the April 2017 Dear Colleague Letter on FLSA Implementation.

Durable Medical Equipment / Personal Emergency Response System:

Please attach the following documents:
Acceptable file types are: pdf, jpg, jeg, png, gif, doc, docx

Business Associates Agreement (BAA):
- Nascentia will send for review and signature along with finalized contract.

EIN, Medicaid Provider Number & NPI number (provide information in the General Information section of this form)

W-9 with legal name and remit address:

Incontinence Products Verification (only applicable to DME providers who offer incontinence supplies):

Provider Compliance Certification (provide information in the Provider Compliance Certification below)
- Certification of a Provider Compliance Program may be required. By signing the Certification Statement for Provider Billing Medicaid, you (or the entity) certify that you (or the entity) have adopted and implemented an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title 18 of the New York Code, Rules and Regulations Part 521. For more information on the Provider compliance Program, please go to the program website at https://omig.ny.gov/compliance/compliance.
- If a 2021 certification is not yet due, please provide a copy of 2019 SSL Certification.

Proof of adequate insurance coverage - General Liability and Professional Liability (ACORD Form with Nascentia Health Options, 1050 West Genesee St, Syracuse, NY 13204, listed in the certificate holder box; minimum requirement of 1 million per occurrence and 3 million aggregate, or umbrella coverage):

Durable Medical Equipment/Personal Emergency Response System Services offered (Check all that apply):

Durable Medical Equipment and Supplies
Incontinence Supplies
Medicare-Authorized DME Provider (Lift Chairs, Wheelchairs, Walkers, etc.)
Medication Dispensing Systems
Personal Emergency Response Systems (PERS) – Basic / Landline
Personal Emergency Response Systems (PERS) – Cellular
Personal Emergency Response Systems (PERS) – GPS
Personal Emergency Response Systems (PERS) – Fall Detection
Other Services
If selected, list “Other Services”:

For Durable Medical Equipment (DME) vendors who supply incontinence products:

The Department of Health (DOH) issued an incontinence supply initiative effective September 1st, 2016. DME companies must now ensure that incontinence products that they dispense to Medicaid members meet minimum quality standards put in place by the DOH.

The minimum standards include:

No plastic (Non-breathable) backed products
Rewet rate of <2.0g
Rate of Acquisition (ROA) of <6 seconds
Retention Capacity >250g
Presence of breathable zones with a minimum value of >100 cubic feet per minute (cfm)
Presence of closure system which allows for multiple fastening and unfastening occurrences

Verification that your incontinence products meet minimum standards must be on file with Provider Relations at VNA Options. Verification must be in the form of test results obtained from an independent testing laboratory.

IF your company purchases incontinence products from Twin Med, LLC, the State’s new preferred supplier, you do not have to verify incontinence product quality standards. Proof that your products are being purchased from Twin Med, LLC will suffice.

Further, most First Quality and Covidien brands meet minimum quality standards, however, verification for these brands must also be on file.

Twin Med verification
or Minimum quality standards verification

Home and Safety Modification:

Please attach the following documents:
Acceptable file types are: pdf, jpg, jeg, png, gif, doc, docx

Business Associates Agreement (BAA):
- Nascentia will send for review and signature along with finalized contract.

EIN, Medicaid Provider Number & NPI number (provide information in the General Information section of this form)

W-9 with legal name and remit address:

Copy of contractor’s license:

Proof of adequate insurance coverage - General Liability (ACORD Form with Nascentia Health Options, 1050 West Genesee St, Syracuse, NY 13204, listed in the certificate holder box; minimum requirement of 1 million per occurrence and 3 million aggregate, or umbrella coverage):

Environmental Modifications and Support Services offered (Check all that apply):

Installation of Ramps (Portable, Threshold, Modular)
Installation of Wheelchair Lifts (Platform, Incline)
Installation of Stair Lifts (Straight, Curved)
Installation of DME Supplies (Grab Bars, Handheld Shower, etc.)
Other Services
If selected, list “Other Services” offered:
Other Home and Safety Modifications
If selected, list “Other Home and Safety Modifications” offered:

Licensed / Certified Professional Services:

Please attach the following documents:
Acceptable file types are: pdf, jpg, jeg, png, gif, doc, docx

Valid state licensure information (provide Licensure/Certification information in the General Information section of this form)

EIN, Medicaid Provider Number & NPI number (provide information in the General Information section of this form)

W-9 with legal name and remit address:

Provider Compliance Certification (provide information in the Provider Compliance Certification below)
- Certification of a Provider Compliance Program may be required. By signing the Certification Statement for Provider Billing Medicaid, you (or the entity) certify that you (or the entity) have adopted and implemented an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title 18 of the New York Code, Rules and Regulations Part 521. For more information on the Provider compliance Program, please go to the program website at https://omig.ny.gov/compliance/compliance.
- If a 2021 certification is not yet due, please provide a copy of 2019 SSL Certification.

Proof of adequate insurance coverage - General Liability and Professional Liability (ACORD Form with Nascentia Health Options, 1050 West Genesee St, Syracuse, NY 13204, listed in the certificate holder box; minimum requirement of 1 million per occurrence and 3 million aggregate, or umbrella coverage):

Services offered (Check all that apply):

Audiology (exam only)
Audiology (hearing aid services available)
Nutritional Counseling
Outpatient Occupational Therapy
Outpatient Physical Therapy
Outpatient Speech Therapy
Podiatry, in Home
Podiatry, in Outpatient Setting
Podiatry, in Skilled Nursing Facility
Prosthetics and Orthotics
Respiratory Therapy
Other Services
If selected, list “Other Services” offered:

Please list License/Certification information for all professionals employed at your facility. Applicable to all licensed staff, including but not limited to: Audiologists, Dietitians, Nutritionists, Optometrists, Opticians, Outpatient Therapists (PT, OT, ST, Respiratory) and Podiatrists.

1.
Name:

License #:

Occupation:

Individual NPI:

Practitioner Medicaid ID:

Practitioner Medicare ID:

Practice Location(s):

2.
Name:

License #:

Occupation:

Individual NPI:

Practitioner Medicaid ID:

Practitioner Medicare ID:

Practice Location(s):

3.
Name:

License #:

Occupation:

Individual NPI:

Practitioner Medicaid ID:

Practitioner Medicare ID:

Practice Location(s):

4.
Name:

License #:

Occupation:

Individual NPI:

Practitioner Medicaid ID:

Practitioner Medicare ID:

Practice Location(s):

5.
Name:

License #:

Occupation:

Individual NPI:

Practitioner Medicaid ID:

Practitioner Medicare ID:

Practice Location(s):

Meals Provider

Please attach the following documents:
Acceptable file types are: pdf, jpg, jeg, png, gif, doc, docx

Business Associates Agreement (BAA):
- Nascentia will send for review and signature along with finalized contract.

EIN, Medicaid Provider Number & NPI number (provide information in the General Information section of this form)

W-9 with legal name and remit address:

Proof of adequate insurance coverage - General Liability and Professional Liability (ACORD Form; must list Nascentia Health Options, 1050 West Genesee St, Syracuse, NY 13204, listed in the certificate holder; minimum requirement of 1 million per occurrence and 2 million aggregate, or umbrella coverage):

Services Offered (Check all that apply):

Congregate Meals
Home Delivered Meals

Skilled Nursing Facility (SNF):

Please attach the following documents:
Acceptable file types are: pdf, jpg, jeg, png, gif, doc, docx

Valid state license(s) or operating certificate(s) (provide Licensure/Certification information in the General Information section of this form)

JCAHO accreditation report (if applicable):

Most recent NYSDOH State Survey & Plan of Correction:

EIN, Medicaid Provider Number & NPI number (provide information in the General Information section of this form)

W-9 with legal name and remit address:

Copy of patient satisfaction survey:

Provider Compliance Certification (provide information in the Provider Compliance Certification below)
- Certification of a Provider Compliance Program is required. By signing the Certification Statement for Provider Billing Medicaid, you (or the entity) certify that you (or the entity) have adopted and implemented an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title 18 of the New York Code, Rules and Regulations Part 521. For more information on the Provider compliance Program, please go to the program website at https://omig.ny.gov/compliance/compliance.
- If a 2021 certification is not yet due, please provide a copy of 2019 SSL Certification.

Proof of adequate insurance coverage - General Liability and Professional Liability (ACORD Form with Nascentia Health Options, 1050 West Genesee St, Syracuse, NY 13204, listed in the certificate holder box; minimum requirement of 1 million per occurrence and 3 million aggregate, or umbrella coverage):

Permanent Facility Identifier:

JCAHO Accreditation:

Yes No N/A

CARF Accreditation:

Yes No N/A

Covered Services offered (Check all that apply):

Adult Medical Day Care (ADHC)
Adult Social Day Care (ADHC)
Audiology (hearing aid dispensing)
Audiology (hearing exam services)
Dentisty (on-site)
Outpatient Occupational Therapy
Outpatient Physical Therapy
Outpatient Speech Therapy
Podiatry (on-site)
Transportation (Day Care)
Transportation (to member appointments)
Vision Care (on-site)

Skilled Nursing Facility Services:

Daily Room and Board
Specialty Beds (Behavioral, Neurological, Ventilation)
Respite Care

For SNFs providing OUTPATIENT THERAPY: Please list License/Certification information for all OT/PT/ST professionals employed at your outpatient facility.

1.
Name:

License #:

Occupation:

Individual NPI:

Practitioner Medicaid ID:

Practitioner Medicare ID:

Practice Location(s):

2.
Name:

License #:

Occupation:

Individual NPI:

Practitioner Medicaid ID:

Practitioner Medicare ID:

Practice Location(s):

3.
Name:

License #:

Occupation:

Individual NPI:

Practitioner Medicaid ID:

Practitioner Medicare ID:

Practice Location(s):

4.
Name:

License #:

Occupation:

Individual NPI:

Practitioner Medicaid ID:

Practitioner Medicare ID:

Practice Location(s):

Transportation Provider:

Please attach the following documents:
Acceptable file types are: pdf, jpg, jeg, png, gif, doc, docx

Business Associates Agreement (BAA):
- Nascentia will send for review and signature along with finalized contract.

EIN, Medicaid Provider Number & NPI number (provide information in the General Information section of this form)

W-9 with legal name and remit address:

Provider Compliance Certification (provide information in the Provider Compliance Certification below)
- Certification of a Provider Compliance Program may be required. By signing the Certification Statement for Provider Billing Medicaid, you (or the entity) certify that you (or the entity) have adopted and implemented an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title 18 of the New York Code, Rules and Regulations Part 521. For more information on the Provider compliance Program, please go to the program website at https://omig.ny.gov/compliance/compliance.
- If a 2021 certification is not yet due, please provide a copy of 2019 SSL Certification.

Copy of DOT Certificate (if applicable):

Proof of adequate insurance coverage - General Liability (ACORD Form with Nascentia Health Options, 1050 West Genesee St, Syracuse, NY 13204, listed in the certificate holder box; minimum requirement of 1 million per occurrence and 2 million aggregate, or umbrella coverage):

Proof of adequate insurance coverage - Automobile coverage (may be listed on the same or different ACORD form detailed above):

DOT Certificate # (Required for wheelchair transportation):

Transportation Services Offered (Check all that apply):

After Hours Transportation
Door to Door Assist
Non-Emergent Ambulance
Stretcher
Wheelchair
Bariatric Wheelchair
Taxi

Upload any additional documentation:

After filling out the necessary Service Provider Applications REMEMBER TO COMPLETE the Attestation, Credentialing Attestation and Release Form and Certification / Affirmation of Accuracy and Completeness.

Provider Compliance Certification
I agree to submit to Nascentia annually a copy of the Certification Statement for Provider Billing Medicaid pursuant to NYS Social Services Law (SOS) § 363-d and Title 18 of the New York Codes, Rules and Regulations (18 NYCRR) Part 521. For more information on the Provider Compliance Program, please go to the program website at https://omig.ny.gov/compliance/compliance

Please Initial:

I confirm that I have submitted a certification statement to Medicaid as required
Please provide a copy:

I confirm that I am not required to submit a certification statement to Medicaid pursuant to NYS Social Services Law (SOS) § 363-d and Title 18 of the New York Codes, Rules and Regulations (18 NYCRR) Part 521

Attestation

I agree to use best efforts to inform Nascentia Health Options in writing within 15 business days if there is any change in the information provided or the answers to questions on the application as a result of developments subsequent to signing this application.

I agree that a photocopy or facsimile of this document with my signature may be accepted with the same authority as the original.

Credentialing Attestation and Release Form

In the past 3 years or presently, has your company or any of its representatives:

1. Had disciplinary actions, criminal proceedings, or other adverse actions initiated against them (this includes license or certification limitations, revocations, suspensions, terminations, or voluntary relinquishment)? (required)

Yes No

2. Been subject of an investigation, or ever been suspended, sanctioned or otherwise excluded from participating in any private, state, or federal health insurance program (examples – Medicare, Medicaid, other Managed Care Organization)? (required)

Yes No

3. Been subject to (in whole or in part) professional liability or malpractice claims, suits, settlements, arbitration proceedings, or complaints? (required)

Yes No

4. Been subject to (in whole or in part) professional liability or malpractice claims, suits, settlements, arbitration proceedings, or complaints? (required)

Yes No

5. Been denied liability insurance (in whole or in part) or had your insurance canceled, involuntarily restricted, denied renewal, or rated up because of the nature volume of claims against your company? (required)

Yes No

If you answered "yes" to any of the above questions, please explain:

Please Initial:

I confirm that there is a process in place to monitor and screen employees, volunteers, governing body members, and downstream entities for Healthcare related criminal convictions. (required)
I confirm that there is a process in place to monitor and screen employees, volunteers, governing body members, and downstream entities against the List of Excluded Individuals (LEIE) –
https://exclusions.oig.hhs.gov/, Excluded Parties List System (EPLS) – https://sam.gov/SAM/, and the New York Exclusions Database – https://www.omig.ny.gov/search-exclusions prior to hiring and monthly thereafter. (required)

Certification / Affirmation of Accuracy and Completeness

I hereby affirm that all information provided in or attached to this application for credentialing/re-credentialing is current, true, correct, accurate and complete to the best of my knowledge and belief, and is furnished in good faith. I understand that any misrepresentation or omission of any fact requested, whether intentional or not, is cause for automatic and immediate rejection and/or termination of the credentialing/re-credentialing process.

I hereby agree to immediately notify Nascentia Health Options if such representation ever ceases to be accurate and true. I understand that this credentialing/re-credentialing review process will occur prior to approval of participation. I hereby authorize Nascentia Health to consult with any third party who may have information bearing on any services that my company provides. I hereby release any person, institution or other party from any liability in connection with the provision of such information or documentation.

Name of Organization: (required)

Authorized Representative Signature: (required*)
Please draw your signature in the space below:

*If you are unable to sign the form electronically, please download the signature page here, sign, and either fax to (315) 671-5129 or email to providerrelations@477home.org.

Authorized Representative Printed Name: (required)

Title: (required)

Date: (required)

(Inital) Subcontractor (required)