For additional information about Aetna's Behavioral Health provider application and credentialing process, or if you want to learn more about Aetna’s participation with the CAQH online application please visit our "Credentialing and Becoming an Aetna Participating Provider" section.

For information obtained during verification from primary sources, as a practitioner you have the right to correct discrepant or erroneous information by working directly with any reporting entities used during the credentialing process.

Medical Providers interested in joining Aetna's managed care network are requested to complete the Health Professionals Medical Plans Application Request.

Behavioral Health Providers interested in joining Aetna's managed care network are requested to complete the following information:

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

Practitioner Information:
*Date of request: month, day, year:		(03/15/2007)
*Full Name of Requestor at Providers Office:		(John Doe)
*Phone Number:		- -  ext.  (000-123-4567
*Practitioner Last Name:
*Practitioner First Name:
Middle Initial:
*Date of Birth: (month, day, year):		/ / (12/15/1950)
Email Address:		(example@sample.com)
*Specialty:		If your Specialty is not listed please call 1-800-353-1232.
*Degree Type:
*Applying as::		Specialist Primary Care Physician Allied
License Number of Practitioner:
State License was issued in:		Select one of the following Alabama Alaska Arkansas Arizona California Colorado Connecticut Dist.of Colum. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Mississippi Missouri Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
*Providers Tax ID Number:		Select E S - Please do not include spaces or dashes. Some providers use the SSN instead.  If joining a participating group, please use the group's Tax ID to associate the request with the participating group.
Are you applying to join an existing group that participates with Aetna? :		Select Yes No
Are you registered with CAQH? :		Select Yes No
CAQH Provider ID::
*Do you have Hospital/Facility Admitting Privileges?:		Select Yes No
If the answer to the above is Yes - Please enter Name and State of the Hospital and/or Faculties(s)s in which you have Admitting Privileges
Hospital Affiliation(s):	State  Select Alabama Alaska Arkansas Arizona California Colorado Connecticut Dist.of Colum. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Mississippi Missouri Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming           Select Alabama Alaska Arkansas Arizona California Colorado Connecticut Dist.of Colum. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Mississippi Missouri Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming           Select Alabama Alaska Arkansas Arizona California Colorado Connecticut Dist.of Colum. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Mississippi Missouri Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming           Select Alabama Alaska Arkansas Arizona California Colorado Connecticut Dist.of Colum. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Mississippi Missouri Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming           Select Alabama Alaska Arkansas Arizona California Colorado Connecticut Dist.of Colum. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Mississippi Missouri Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming

Service Location Information:
* Service Location Address:
Suite:
*City:
*State:		Select one of the following Alabama Alaska Arkansas Arizona California Colorado Connecticut Dist.of Colum. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Mississippi Missouri Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
*County:
*ZIP:		(12345-6789)
*Phone Number:		- -
*Fax Number:		- - (000-123-4567)
Practice/Group Name:

Mailing Address:
*The Mailing Address is: the same as different than the primary service location's address above.
*Mailing Address:
Suite:
*City:
*State:		Select one of the following Alabama Alaska Arkansas Arizona California Colorado Connecticut Dist.of Colum. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Mississippi Missouri Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
ZIP:		- (12345-6789)

NPI Information:
NPI Contact Name:
Phone:		- -
Entity Type:
NPI Number:
Does NPI apply to all providers using this Tax ID:		Select Yes No
Does this NPI apply to all TAX ID for this provider only?:		Select Yes No
Does this NPI apply to all Service Locations and Billing Addresses for this Tax ID?:		Select Yes No
Does this NPI apply to all Service Locations and Billing Addresses for this provider only?:		Select Yes No

Populations You Work With:
Children Ages: 0 to12:
Adolescents Ages: 12 to 17:
Adults Ages:18 to 64:
Seniors Ages: 65 to 150:
Handicap Accessible:		Select Yes No

Language Spoken
American Sign Language:		Select Yes No
Select a Language :		Achinese Acoli Adangme Afrihili (Artifical Lang) Afrikaans Afroasiatic (Other) Akan Akkadian Albanian Aleut Algonquian (Other) Altaic (Other) Amharic Apache Languages Arabic Aramaic Arapahp Arawak Armenian Artficial (Other) Assamese Athapascan (Other) Austonesian (Other) Avaric Avestan Awadhi Aymara Azerbaijani Balinese Baltic Baluchi Bambara Bamileke Languages Banda Bantu (Other) Basa Bashkir Basque Batak Beja Belarusian Bemba Bengali Berber Bhopuri Bikol Bini Bislama Braj Breton Bugis Bulgarian Burmese Caddo Cantonese Carib Catalan Caucasian Cebuano Celtic (Other) Central American Indian Chagatai Chaldean Chamic Languages Chamorro Chechen Cherokee Cheyenne Chibcha Chinese Chinook Jargon Choctaw Church Slavic Chuvash Coptic Cornish Cree Creek Creole and Pidgins(Other) Creoles and Pidgins (Eng) Creoles and Pidgins (Fre) Creoles and Pidgins (Por) Cushitic Czech Dakota Danish Dayak Delaware Dinka Divehi Dogri Dravidian Duala Dutch Dutch, Middle (1050-1350) Dyula Efik Egyptian Ekajuk Elamite Eskimo Languages Esperanto Estonian Ethiopic Ewe Ewondo Fang Fanti Faroese Farsi Fijian Finnish Finno-Ugric Fon French Friesian Fula Ga Gaelic (Scots) Gallegan Ganda Gayo Gbaya Georgian German Germanic Gilbertese Gondi Gorontalo Gothic Grebo Greek, Modern Guarani Gujarati Haida Hausa Hawaiian Hebrew Herero Hiligaynon Himachali Hindi Hiri Motu Hmong Hungarian Hupa Iban Icelandic Igbo Ijo Iloko Indic Indo-European (Other) Indonesian Interlingua Iranian Irish Iroquoian (Other) Italian Japanese Javanese Judeo-Arabic Judeo-Persian Kabyle Kachin Kamba Kannada Kanuri Kara-Kalpak Karen Kashmiri Kawi Kazakh Khasi Khmer Khoisan (Other) Khotanese Kikuyu Kimbundu Kinyarwanda Kongo Konkani Korean Kpelle Kru Kuanyama Kurdish Kurukh Kusaie Kutenai Kyrgyz Ladino Lahnd Lamba Langue d'oc Lao Lapp Latin Latvian Lingala Lithuanian Lozi Luba-Katanga Luba-Lulua Luiseno Lunda Luo (Kenya and Tanzania) Lushai Macedonian Madurese Magahi Maithali Makasar Malagasy Malay Malayalam Maltese Mandarin Mandingo Manipuri Manobo Languages Manx Maori Mapuche Marathi Marshall Marwari Masai Mayan Languages Mende Micmac Minangkabau Mohawk Moldavian Mon-Khmer (Other) Mongo-Nkundu Mongolian Moore Munda Nahuatl Nauru Navajo Ndebele (Zimbabwe) Ndonga Nepali Newari Nias Niger-Kordofanian Nilo-Saharan (Other) Niuean North American Indian Northern Sotho Norwegian Nubian Languages Nyamwezi Nyanja Nyankole Nyoro Nzima Ojibwa Old Norse Old Persian (600-400) Oriya Oromo Osage Ossetic Otomian Languages Pahlavi Palauan Pali Pampanga Pangasinan Papiamento Papuan-Australian (Other) Persian Philippine Polish Ponape Portuguese Prakrit Languages Provencal (to 1500) Punjabi Pushto Quechua Rajasthani Rapanui Rarotongan Rhaeto-Romance Romance (Other) Romanian Romany Rundi Russian Salishan Languages Samaritan Aramaic Samoan Sandawe Sango Sanskrit Santali Sasak Scots Selkup Semitic (Other) Serbo-Croatian (Cyrilic) Serbo-Croatian (Roman) Serer Shan Shona Sidamo Sign Siksika Sindhi Sinhalese Sino-Tibetan (Other) Siouan (Other) Slavic Slovak Slovenian Sogdian Somali Songhai Soninke Sorbian Languages Sotho South American Indian Spanish Sukuma Sumerian Sundanese Susu Swahili Swazi Swedish Syriac Tagalog Tahitian Taiwanese Tajik Tamashek Tamil Tatar Telugu Temne Terena Tetum Thai Tibetan Tigre Tigrinya Tiv Tlingit Tok Pisin Tokelauan Tonga (Nyasa) Tonga (Tonga Islands) Truk Tsimshian Tsonga Tswana Tumbuka Turkish Turkish, Ottoman Turkmen Tuvalu Twi Ugaritic Uighur Ukrainian Umbundu Undetermined Urdu Uzbek Vai Venda Vietnamese Votic Wakashan Languages Walamo Waray Washo Welsh Wolof Xhosa Yao (Bantu) Yapese Yiddish Yoruba Zande Zapotec Zenaga Zulu Zuni Press Control C to select multiple languages

Provider Practice Focus
Please check up to (8) areas of focus.:
Addiction Psychiatry	Dialectic Behavioral Therapy	Neuropsych Testing
Addiction Specialist	Dissociative Disorder	Obsessive-Compulsive Disorder
Adolescent Psychiatry	Domestic Violence	Occupational Issues
Adolescent Psychology	Eating Disorders	Pain Management
Anxiety Disorders	Gay/Lesbian Issues	Parenting Issues
Attention Deficit Disorder	Gender Identity	Personality Disorders
Bereavement/Grief Counseling	Geriatric Psychiatry	Pharmacology/Medication Management
Biofeedback	Group Therapy	Post-Traumatic Stress Disorder
Certified Employee Assistance Professional	Health/Physical Disabilities	Psychological Testing
Child Abuse	Hearing Impaired	Psychotic Disorders
Child Psychiatry	HIV/AIDS	Sexual/Physical Abuse
Child Psychology	Hypnotherapy	Sexual Dysfunction
Christian Counseling	Learning Disabilities	Stress Management
Codependency Issues	Life Management Counseling	Substance Abuse Professional (SAP)
Cognitive Behavioral Therapy	Managed Disability	Women's Issues
Co morbidity	Marriage&Family Therapy	Other:
Crisis Intervention	Men's Issues
Detoxification	Mood Disorders