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                Step 1: Complete your request for

                participation

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We support your mission to care for the health, safety and

well-being of your patients.

Step 1 of 4 | Practitioner: Personal Information

 

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

Incorrect tax ID will delay the application request process.If joining a participating group, please use the group's Tax ID to associate the request with the participating group.

Step 2 of 4 | Practitioner : Professional Information

 

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

 

*Are you affiliated with any hospitals?                                                                    

If the answer to the above is Yes,  please enter the name of the hospital(s) in which your are affiliated

The provider ID should be 8 numbers.

Step 3 of 4 | Practice Information

 

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

A post office box is not acceptable primary service address. Please do not use abbreviations for address (i.e., "Rd" must be entered as "Road")

 

For all Minnesota applicants                   Are you applying for the Allina

Health | Aetna joint venture network?

E.g., 123-456-7890

Please enter the email address of the individual authorized to sign the agreement

Step 4 of 4 | National Provider Identification (NPI) information (optional)

A 10 Digit type 1/Individual NPI number must be entered if you are a physician(MD/DO)

Does this NPI apply to:

Are all providers using this Tax ID?
Are all tax ID's for this provider?
Are all service locations and billing addresses for this tax ID?
Are all service locations and billing addresses for this provider?