Medical Application Request Form

Medical

Interested in joining the Aetna network? Learn more about our application and credentialing process here. The site also has information on the Council for Affordable Quality Healthcare's (CAQH's) Universal Provider Datasource® and ProviderSource™ (for Washington State licensed practitioners). 

Or to get an application, please complete the form below: 

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

All fields marked with a RED asterisk (*) are required in order to proceed.

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Information

1) Information
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Incorrect date of birth will delay the application request process

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

Must select Specialty first

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Service Location And Mailing Address

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

3) National Provider Identifier (NPI) information
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Further Details

4) Please provide further details




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