Mid-Level Practitioner Form - Health Care Professionals

Practitioner Information

All fields marked with an asterisk (*) are required.

*Employment Start Date Note: The practitioner's effective date will be the later of the submission date or his/her employment start date

*Last Name

*First Name

M.I.

*Practitioner TYPE

*DEGREE TYPE

*PRACTICE TYPE

Primary Care

Ob/Gyn

Specialty

*Date of birth

*GENDER

Male

Female

License and Tax Information

All fields marked with an asterisk (*) are required.

*State License Number

*STATE LICENSE EXPIRATION (ENTERED AS MM/DD/YYYY)

Drug Enforcement Administration (DEA) Number Must be 2 letters and 7 digits.

DEA Expiration

*TAX ID TYPE

*Tax ID Number

Please do not include spaces or dashes. If joining a participation group, please use the group's tax ID to associate the request with the participating group.

HOSPITAL ADMITTING PRIVILEGES

Yes

Address and Contact Information - Part A

All fields marked with an asterisk (*) are required.

A. SERVICE LOCATIONS

Primary service address and contact information

*Group/Practice/Department Name

*Primary service address Please do not include a P.O Box

Address 2

*City

*STATE

*5 Digit Zip code

*Primary Service PHONE NUMBER (10 DIGITS)

Primary Service FAX NUMBER (10 DIGITS)

*Is the primary location wheelchair accessible?

Yes

Primary service address and contact information

*Group/Practice/Department Name

*Primary service address Please do not include a P.O Box

Address 2

*City

*STATE

*5 Digit Zip code

*Primary Service PHONE NUMBER (10 DIGITS)

Primary Service FAX NUMBER (10 DIGITS)

*Is the primary location wheelchair accessible?

Yes

Service address and contact information 2

*Group/Practice/Department Name

*Primary service address Please do not include a P.O Box

Address 2

*City

*STATE

*5 Digit Zip code

*Primary Service PHONE NUMBER (10 DIGITS)

Primary Service FAX NUMBER (10 DIGITS)

*Is the primary location wheelchair accessible?

Yes

Primary service address and contact information

*Group/Practice/Department Name

*Primary service address Please do not include a P.O Box

Address 2

*City

*STATE

*5 Digit Zip code

*Primary Service PHONE NUMBER (10 DIGITS)

Primary Service FAX NUMBER (10 DIGITS)

*Is the primary location wheelchair accessible?

Yes

Service address and contact information 2

*Group/Practice/Department Name

*Primary service address Please do not include a P.O Box

Address 2

*City

*STATE

*5 Digit Zip code

*Primary Service PHONE NUMBER (10 DIGITS)

Primary Service FAX NUMBER (10 DIGITS)

*Is the primary location wheelchair accessible?

Yes

Service address and contact information 3

*Group/Practice/Department Name

*Primary service address Please do not include a P.O Box

Address 2

*City

*STATE

*5 Digit Zip code

*Primary Service PHONE NUMBER (10 DIGITS)

Primary Service FAX NUMBER (10 DIGITS)

*Is the primary location wheelchair accessible?

Yes

Primary service address and contact information

*Group/Practice/Department Name

*Primary service address Please do not include a P.O Box

Address 2

*City

*STATE

*5 Digit Zip code

*Primary Service PHONE NUMBER (10 DIGITS)

Primary Service FAX NUMBER (10 DIGITS)

*Is the primary location wheelchair accessible?

Yes

Service address and contact information 2

*Group/Practice/Department Name

*Primary service address Please do not include a P.O Box

Address 2

*City

*STATE

*5 Digit Zip code

*Primary Service PHONE NUMBER (10 DIGITS)

Primary Service FAX NUMBER (10 DIGITS)

*Is the primary location wheelchair accessible?

Yes

Service address and contact information 3

*Group/Practice/Department Name

*Primary service address Please do not include a P.O Box

Address 2

*City

*STATE

*5 Digit Zip code

*Primary Service PHONE NUMBER (10 DIGITS)

Primary Service FAX NUMBER (10 DIGITS)

*Is the primary location wheelchair accessible?

Yes

Service address and contact information 4

*Group/Practice/Department Name

*Primary service address Please do not include a P.O Box

Address 2

*City

*STATE

*5 Digit Zip code

*Primary Service PHONE NUMBER (10 DIGITS)

Primary Service FAX NUMBER (10 DIGITS)

*Is the primary location wheelchair accessible?

Yes

Address and Contact Information - Part B

All fields marked with an asterisk (*) are required.

B. EMAIL AND BILLING ADDRESS DETAILS

*EMAIL ADDRESS Formatted as example@sample.com

*VERIFY EMAIL ADDRESS Formatted as example@sample.com

BILLING ADDRESS DETAILS

The Billing Address is the same as the primary service location's address above.

*BILLING ADDRESS

Billing Address 2

*city

*STATE

*5 Digit Zip code

*Billing Phone Number (10 Digits)

Billing Fax Number (10 Digits)

National Provider Identifier (NPI) Information

All fields marked with an asterisk (*) are required.

*NPI Number A 10 digit number must be entered.

*Does NPI apply to all providers using this tax ID?

Yes

*Does this NPI apply to all tax ID for this provider only?

Yes

*Does this NPI apply to all service locations and billing addresses for this tax ID?

Yes

*Does this NPI apply to all service locations and billing addresses for this provider only?

Yes

ELECTRONIC CORRESPONDENCE

I prefer to receive Aetna correspondence electronically

Practitioner Information

License and Tax Information

Address and Contact Information - Part A

Address and Contact Information - Part B

National Provider Identifier (NPI) Information

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