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.