Meals Provider Vendor Application

Please complete the Meal Provider Vendor Application by:

Nascentia Health Options
Attn: Provider Relations Department
1050 West Genesee Street
Syracuse, NY 13204-2215

Please attach the following documents with the application:

  • Business Associates Agreement (BAA)
  • EIN, Medicaid Provider Number, & NPI number (provide information below)
  • 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 listed in the certificate holder; minimum requirement of 1 million per occurrence and 2 million aggregate, or umbrella coverage)

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