Behavioral Health Provider Application Request

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.

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Practitioner Information

1) Practitioner Information
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Incorrect date of birth will delay the application request process.

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.

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.





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Service Location Information

 

2) 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
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Populations you work with

 

5) Populations you work with
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Language spoken

 

6) Language spoken

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

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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