Medical - Request for Participation Form
Medical
Please complete this form if you are interested in joining the Aetna's network.
If you already work with us and need to update your Tax ID (TIN), do not use this form. Instead, fax us a letter and your new W-9 form to 859-455-8650. Include the reason for the change and the affected service address(es).
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 Medversant / ProviderSource™ (for practitioners located in Washington state).
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.