Application request

Behavioral health

Interested in joining the Aetna network? Learn more about our application and credentialing process here. The site also has information on the Council for Affordable Quality Healthcare's (CAQH's) Universal Provider Datasource® and ProviderSource™ (for Washington State licensed practitioners).

Or to get an application, please complete the form below:

As a practitioner, you have the right to correct discrepant or erroneous information obtained during the credentialing process by working directly with any reporting entities.

All fields marked with a RED asterisk(*) are required in order to proceed.

#1 Practitioner Information:

* : / /
(03/15/2007)

* :
(John Doe)

* : - -  ext. 
(000-123-4567 ext. 8910)

* :

* :

:

* : / /
(12/15/1950)
Incorrect date of birth will delay the application request process.
 
* :
* :
(example@sample.com)
Please enter the email address of the individual authorized to sign the agreement.

* :

If your Specialty is not listed please call 1-800-353-1232.

* :
Click here for Degree Acronym Definitions  (PDF, 111 KB)

* : Specialist
Primary Care Physician
Allied

:

:

* : -
Please do not include spaces or dashes. Some providers use the SSN instead.  If joining a participating group, please use the group's Tax ID to associate the request with the participating group.
Incorrect TIN will delay the application request process.
 
:

:

:

* :



If the answer to the above is Yes, please enter name and state of the hospital and/or faculties(s)s in which you have admitting privileges.

:  State 
        
         
         
         

#2 Service Location Information:

:

:

* :

* :

* :

* Zip/postal code:   
(12345-6789)

* : - -
(000-123-4567)

* : - -
(000-123-4567)

:


#3 Mailing Address:

* : the primary service location's address above.

* :

:

* :

* :

* : -
(12345-6789)


#4 National Provider Identifier (NPI) information:

:

: - -

:

:

:

:

:

:


#5 Populations you work with:

:

:

:

:

:


#6 Language spoken

:

:

Press Control C to select multiple languages




#7 Provider Practice Focus

:
Addiction psychiatry Detoxification Neuropsych testing
Addiction specialist Dialectic behavioral therapy Obsessive-compulsive disorder
Adolescent psychiatry Dissociative disorder Occupational issues
Adolescent psychology Domestic violence Pain management
Anxiety disorders Eating disorders Parenting issues
Applied Behavioral Analyst Gay/lesbian issues Personality disorders
Attention deficit disorder Gender identity Pharmacology/medication management
Bereavement/grief counseling Geriatric psychiatry Post-traumatic stress disorder
Biofeedback   Group therapy Psychological testing
Certified employee assistance
        professional
Health/physical disabilities Psychotic disorders
Child abuse Hearing impaired Sexual/physical abuse
Child psychiatry HIV/AIDS Sexual dysfunction
Child psychology Hypnotherapy Stress management
Christian counseling Learning disabilities Substance abuse professional (SAP)
Codependency issues  Life management counseling Women's issues
Cognitive behavioral therapy Managed Disability Other:
Co morbidity  Marriage & family therapy
Crisis intervention Men's issues
Depression Mood disorders  
   

*    


 

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