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Medical Application Request Form

Medical

Please complete this form if you are interested in joining the Aetna's network.

If you need more information about our application and credentialing process, use the link below. You will also find information on the Council for Affordable Quality Healthcare's (CAQH's) ProView® and ProviderSource™ (for Washington State licensed practitioners).

Information about application and credentialing process

As a practitioner, you have the right to correct any information obtained during the credentialing process by working directly with the reporting entities. 

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

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Information

1) Information

Please do not include spaces or dashes. 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.

Degree acronym definitions (PDF, 111 KB) 

*Applying as
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Service Location And Mailing Address

2) Primary Service Location And Mailing Address
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National Provider Identifier (NPI) Information

3) National Provider Identifier (NPI) information
Does NPI apply to all providers using this tax ID?
Does this NPI apply to all tax ID for this provider only?
Does this NPI apply to all service locations and billing addresses for this tax ID?
Does this NPI apply to all service locations and billing addresses for this provider only?
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Further Details

4) Please provide further details




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