Behavioral Health Provider Application

1 of 7

Practitioner Information

1) Practitioner Information

* First and last name of requestor at provider's office

* Phone number (10 digits)

Phone ext.

* Practitioner last name

* Practitioner first name

Middle initial

* Date of birth (entered as mm/dd/yyyy)

Incorrect date of birth will delay the application request process.

* Email address (formatted as example@sample.com)

Please enter the email address of the individual authorized to sign the agreement.

* Verify Email Address (formatted as example@sample.com)

* First and last name of office manager or other party responsible for credentialing

* Email address (formatted as example@sample.com)

Please enter the email address of the individual responsible for credentialing.

* Phone number (10 digits)

Fax number (10 digits)

2) Practitioner’s Licensure Information

* Specialty

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

* Degree type

Degree acronym definitions

*Applying as

Specialist

Primary Care Physician

Allied

* I am interested in joining the Aetna network as:

* License number of practitioner

* State license was issued in

* Provider's Tax Identification number (TIN) type

* Provider tax ID number (TIN)

Incorrect TIN will delay the application request process. 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.

*Are you applying to join an existing group that participates with Aetna?

Yes

*Are you registered with Council for Affordable Quality Healthcare (CAQH)?

Yes

CAQH provider ID number

This ID should be 8 numbers.

*Do you have hospital/facility admitting privileges?

Yes

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.

Hospital affiliation 1

Hospital affiliation 2

Hospital affiliation 3

Hospital affiliation 4

Hospital affiliation 5

2 of 7

Primary Service Location Information

3) Primary Service Location Information

*Is this location wheelchair accessible?

Yes

* Address (A Post Office Box is not an acceptable primary service address)

Please do not use abbreviations for address (i.e., "Rd" must be entered as "Road")

* City

*State

*5 digit ZIP code

For all Minnesota Applicants: Are you applying for the Allina Health | Aetna Joint Venture Network?

* County

* Phone number (10 digits)

* Fax number (10 digits)

Practice/group name

Previous Next

3 of 7

Mailing Address

4) Mailing Address

* The mailing address and the primary service location's address above are:

* Mailing address

Please do not use abbreviations for address (i.e., "Rd" must be entered as "Road")

* City

*State

*5 digit ZIP code

Previous Next

4 of 7

National Provider Identifier (NPI) information

5) National Provider Identifier (NPI) information

Primary NPI contact first and last name

Primary NPI contact's phone number (10 digits)

Primary NPI Type

Primary NPI number

A 10 digit type 1/individual NPI number must be entered if you are a physician (MD/DO).

Does NPI apply to all providers using this tax ID?

Yes

Does this NPI apply to all tax ID for this provider only?

Yes

Does this NPI apply to all service locations and billing addresses for this tax ID?

Yes

Does this NPI apply to all service locations and billing addresses for this provider only?

Yes

Secondary NPI Contact First and Last Name

Secondary NPI Type

Secondary NPI number

Previous Next

6 of 7

Language spoken

Below, select up to three languages spoken other than English. Choose "Other" if the language spoken is not listed in the drop downs.

7) Languages spoken

*American sign language

Yes

First language spoken by provider other than English

Second language spoken by provider other than English

Third language spoken by provider other than English

Previous Next

Behavioral Health Provider Application Request