Medical Application Request Form

Medical

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   Please provide the following information:

*   :
*   :
:
*   : / /  
(12/31/2006)
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.

*   : - -  
(000-123-4567)
*   : - -  
(000-123-4567)

*   : -
Please do not include spaces or dashes. 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 your Specialty is not listed please call 1-800-353-1232.

*   :  
Must select Specialty first
Click here for Degree Acronym Definitions  (PDF, 111 KB)

*   : Primary Care Physician (PCP)
Specialist
Allied Health

*   :  
*   :
:

#2   Please provide your service location and mailing address:

*   :
*   :
*   :
*   :  
*   : -  
(12345-6789)

* The Mailing Address is the primary service location's address above.

*   :
*   :
*   :  
*   : -  
(12345-6789)

#3   National Provider Identifier (NPI) information:

:

: - -  

:  

:  

:  

:  

:  

:  


#4   Please provide further details:

: Usage Percent  

Usage Percent  

Usage Percent  

Usage Percent  

Usage Percent

*          
  

 

 

Information Sessions

Your request has been sent successfully if you receive a confirmation after clicking the "Submit" button.

Important! Please check this form carefully before clicking on the "Submit" button. Some browsers will not keep your information, and you will have to re-type all of it if you miss filling in any of the required fields.