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Behavioral Health Provider Application Request

Behavioral Health

Please complete this form if you are interested in joining Aetna's network.

If you need more information about our application and credentialing process, use the link below. You will also find information on the Council for Affordable Quality Healthcare's (CAQH's) Universal Provider Datasource® and ProviderSource™ (for Washington State licensed practitioners).

Information about application and credentialing process

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

All fields marked with a RED asterisk (*) are required.

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Practitioner Information

1) Practitioner Information
*Applying as

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.

Are you applying to join an existing group that participates with Aetna?
Are you registered with CAQH?
*Do you have hospital/facility admitting privileges?

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.

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Service Location Information


2) Primary Service Location Information
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Mailing Address


3) Mailing Address
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National Provider Identifier (NPI) information


4) National Provider Identifier (NPI) information
Does NPI apply to all providers using this tax ID?
Does this NPI apply to all tax ID for this provider only?
Does this NPI apply to all service locations and billing addresses for this tax ID?
Does this NPI apply to all service locations and billing addresses for this provider only?
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Populations you work with


5) Populations you work with
Populations you work with
Handicap accessible
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Language spoken


6) Language spoken
American sign language
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Provider Practice Focus


7) Provider Practice Focus

Please check up to (8) areas of focus

*Do you agree to the Email Acknowledgement?

Please note that completing the request form does not guarantee participation in our network.

We are a participant in the Council for Affordable Quality Healthcare (CAQH) initiative. You should receive our acknowledgement to your application request within 7-10 business days.  

Providers who meet Aetna’s eligibility requirements should watch for a CAQH registration package via U.S. mail within 10-14 business days unless there is an existing CAQH record already established through past affiliation with us or through affiliation with another health plan using the CAQH application. 

Providers applying for participation may be contacted by a representative from Aetna or one of Aetna’s subsidiary companies, including Cofinity and Coventry.

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