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Medical - Request for Participation Form


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.

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1) Practitioner Information

An incorrect date of birth will delay the application request process


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


Providers joining a participating group must enter the participating group's Tax ID.

Physicians select your specialty. All others select your provider type.

*Applying as

This ID should be 8 numbers.

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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


A 10 digit type 1/individual NPI number must be entered if you are a physician (MD/DO).

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

*Do you agree to the Email Acknowledgement?

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