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Facility Request Form to Join the Aetna Network

Want to contract with us? Complete this form if you are a hospital, facility or ancillary provider only.

 Individual physicians/providers or physician/provider groups (type 1) should complete an NPI type 1 individual application.  

Complete an NPI type 1 individual application

Questions about the individual physician/provider or physician/provider groups application process? 

Read our Joining the Network FAQs

Once you complete the form below, we will review your request and make a decision within 60 days. 

  • If the panel is open and we intend to pursue a contract, an Aetna Network Manager will contact you to start the formal credentialing process.
  • If the panel is not open or we do not intend to pursue a contract, you will be notified by letter or email that the request has been denied.
  • If this is an NPI type 1 individual request, we will automatically deny the application and you will be notified of this action by letter or email.

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

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New facility information – Please submit one application per state.

New facility information – Please submit one application per state.

*Do you confirm this is a type 2 facility NPI?

If this is a type 1 NPI, you must complete a type1 application request form.

*Product or Plan (select all that apply)
Facility Type (select all that apply)
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Facility Information

Facility Information

A 9 digit number is required. Please do not include spaces or dashes.

A 10 digit number is required. Please do not include spaces or dashes.

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Facility Primary Contact Information

Facility Primary Contact Information

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Medicare Information

Medicare Information

Medicare type (select all that apply)

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