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Join the First Health network – Medical

Complete this form if you want to join our First Health network only. If you'd like to join both Aetna and First Health, you should apply using only the Aetna Medical Request for Participation form

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

1) Practitioner information

Incorrect date of birth will delay application request. Enter as MM/DD/YYYY
Email address of person signing agreement, formatted as
Formatted as
Primary service location phone number
Primary Service Location Fax
Enter the provider's tax ID number type
An incorrect tax ID number will delay the application process. Please do not include spaces or dashes. If joining a participating group, please use the group’s tax ID number to link your request with the participating group.
Physicians select your specialty. All others select your provider type. If your specialty/provider type is not listed please call 1-800-353-1232
*Applying as
Submit one application per state.
This ID must be 8 numbers.

2) Primary service location and mailing address

Physical address

Do not use abbreviations for address (i.e., "Rd" must be entered as "Road") No PO boxes.

e.g. Sussex County

Mailing address

Submit one application per state.

3) National Provider Identifier (NPI) information

Enter NPI contact first and last name
Enter NPI contact's phone number. Must be 10 digits
A 10 digit type 1/individual NPI number must be entered if you are a physician (MD/DO).

4) Contract network selection

Is the NPI contact person also the contact for contracting?
Are you interested in joining the First Health® Network?

5) Hospital affiliations

*Do you agree to the Email Acknowledgement?

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