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Medical Application Request | Behavioral Health Professionals Application Request

Please select your segment

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.

1 Practitioner Information:

*:
(03/15/2007)

*:
(John Doe)

*: - -  ext. 
(000-123-4567

*:

*:

:

*: / /
(12/15/1950)

:
(example@sample.com)

*:
If your Specialty is not listed please call 1-800-353-1232.

*:
*: Specialist
Primary Care Physician
Allied

:

:

*: -
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.

:

:

:

*:



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
: State 
         
         
         
         

1 Service Location Information:

:

:

*:

*:

*:

*:   
(12345-6789)

*: - -

*: - -
(000-123-4567)

:


1 Mailing Address:

*: the primary service location's address above.

*:

:

*:

*:

: -
(12345-6789)


1 NPI Information:

:

: - -

:

:

:

:

:

:


1 Populations You Work With:

:

:

:

:

:


1 Language Spoken

:

:
Press Control C to select multiple languages


1 Provider Practice 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  
   


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