Behavioral Health Provider Application Request

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Practitioner Information

1) Practitioner Information

*Date of request

/

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

*Phone number

-

Phone ext.

*Practitioner last name

*Practitioner first name

Middle initial

*Date of birth

/

Incorrect date of birth will delay the application request process.

*Email address

*Verify Email Address

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

*Specialty

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

*Degree type - Please select a specialty (above) before selecting a degree type

Degree acronym definitions (PDF, 111 KB)

*Applying as

Specialist

Primary Care Physician

Allied

*License number of practitioner

*State license was issued in

*Providers tax ID number

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?

Yes

No

Are you registered with CAQH?

Yes

No

CAQH provider ID

*Do you have hospital/facility admitting privileges?

Yes

No

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

Service Location Information

2) Primary Service Location Information

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

*County

*Phone number

-

*Fax number

-

Practice/group name

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Mailing Address

3) Mailing Address

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

*Mailing address

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National Provider Identifier (NPI) information

4) National Provider Identifier (NPI) information

NPI contact name

Phone number

-

Entity type

NPI number

Does NPI apply to all providers using this tax ID?

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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Populations you work with

5) Populations you work with

Populations you work with

Children ages: 0 to12

Adolescents ages: 12 to 17

Adults ages: 18 to 64

Seniors ages: 65 to 150

Handicap accessible

Yes

No

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Language spoken

6) Language spoken

American sign language

Yes

No

Select a language

Press Control to select multiple languages

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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?

I agree

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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