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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

An 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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Incorrect tax ID will delay the application request process. 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.

If your specialty is not listed, please call 1-800-353-1232.

*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

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A 10 digit number must be entered.

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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