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Mid-Level Practitioner Form

Credentialing is not required. Welcome letters will not be sent. However, please complete this form to be listed in DocFind, our online provider directory. Please check DocFind to verify your listing within 45 days of submitting form.

Important note: Please do not complete this form if you need to submit more than 10 nurse practitioners, nurse midwives, physician assistants or clinical nurse specialists. You should contact your Aetna network representative for assistance. 

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

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Information

1) Information

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

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*Practice type
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*Gender
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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.

Hospital admitting privileges
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Service Address and Contact Information

2) Service Address and Contact Information
Primary service address and contact information

Please do not include a P.O Box

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Billing Information

3) Billing Information
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National Provider Identifier (NPI) Information

4) National Provider Identifier (NPI) Information
*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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Additional Information

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