Recredentialing Form

Please complete the Recredentialing form by:

  • completing the online form below in its entirety
  • downloading the Recredentialing form (pdf), completing it 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

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

Questions: Call 315.477.9820

    General Information:

    Phone (include area code): (required)

    Fax (include area code): (required)

    Billing Phone (include area code): (required)

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

    Medicare Certification:


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

    2.

    3.

    4.


    Parent Company Name and Contact Information (if applicable):

    Primary Contact Person Phone (include area code):


    Location Information

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






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


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



     

    Please check all items applicable to your location:











    ****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****



    Service Provider Applications

    Please select what type of service provider(s) you are re-credentialing for:










    Complete the required sections for each service provider you are recredentialing for. After completing the General Information, Location Information and the necessary Recredentialing forms REMEMBER TO COMPLETE the Attestation, Recredentialing Attestation and Release Form and Certification / Affirmation of Accuracy and Completeness.

    Adult Day Care:

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







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

    JCAHO Accreditation:




    CARF Accreditation:




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
























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























    Durable Medical Equipment / Personal Emergency Response System:

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










    Home and Safety Modification:

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









    Licensed / Certified Professional Services:

    Services offered (Check all that apply):
















    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.

    2.

    3.

    4.

    5.

    Meals Provider

    Services Offered (Check all that apply):


    Skilled Nursing Facility (SNF):




    JCAHO Accreditation:


    CARF Accreditation:


    Covered Services offered (Check all that apply):













    Skilled Nursing Facility Services:





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

    1.

    2.

    3.

    4.

    Transportation Provider:


    Transportation Services Offered (Check all that apply):







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

    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.

    Recredentialing 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)


    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)


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


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


    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)


    Please Initial:


    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.