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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 already work with us and need to update your Tax ID (TIN), do not use this form. Instead, log in to NaviNet or the electronic transaction vendor that you use.

Log in to NaviNet 

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

Incorrect date of birth will delay the application request process

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Please enter the email address of the individual authorized to sign the agreement

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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.

If your Specialty is not listed please call 1-800-353-1232

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
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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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