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To nominate a physician to participate in Aetna Inc.'s provider network, complete the form below. Prior to submitting your nomination, check DocFind or ask the provider about his/her network status.

The nomination process may take up to 3-6 months. Providers must satisfy our business needs and requirements, including, but not limited to Aetna's credentialing and contracting requirements. This nomination does not guarantee that the provider will be accepted into the network.

Please use this form to nominate an individual medical provider only. Please do not submit nominations for groups, facilities or IPAs.

This form is not applicable to dental provider nominations.

Date:

Your Information
Name*
Last First MI
Phone Number* (9999999999)
E-mail*
Employer Name*

Provider Information
Provider Name*
Last First MI
Specialty Type*
Address*
 
 
City* State* Zip*
County
Physician Office Number* (9999999999)