Medical Application Request | Behavioral Health Professionals Application Request

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Medical Application Request

For additional information about Aetna's 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.

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

Medical 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.

Please provide the following information:
*Last Name:
*First Name:
Middle Initial:
*Date of Birth:		/ / (12/31/2006)
*Email Address:		(example@sample.com)
*Phone Number:		- - (000-123-4567)
*Fax Number:		- - (000-123-4567)
*Tax ID:		Select one of the following E - Employee Identification Number S - Social Security Number - 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.
*Specialty:		Select one of the following Acupuncturist Adolescent_and_Young_Adult_Medicine Adolescent_Medicine Adolescent_Medicine_Pediatric Aerospace_Medicine Allergy_and_Immunology Anesthesiology Angiography_and_Interventional_Radiology Audiologist Blood_Banking_Transfusion_Medicine Body_Imaging Cardiology Cardiovascular_Disease Child_Abuse Child_Neurology Child_Neurophysiology Chiropractor Clinical_Molecular_Genetics Clinical_Laboratory_Dermatological_Immunology Clinical_Biochem_Genetics Clinical_Cardiac_Electro_Physiology Clinical_Cytogenetics Clinical_Genetics_MD Clinical_Neurophysiology Critical_Care_Medicine Critical_Care_Medicine_Anesthesiology Critical_Care_Medicine_Obstetrics_Gynecology Cytopathology Dermatology Dermatopathology Dermatopathology_Dermatology Dermatopathology_Pathology Developmental_Behavioral_Pediatrics Diagnostic_Roentology Diagnostic_Ultrasound Emergency_Medical_Services Emergency_Medicine Endocrinology Endocrinology_Diabetes_Metabolism Endocrinology_Reproductive Facial_Plastic_Surgery Family_Practice Gastroenterology General_Practice Geriatric_Medicine_Family_Practice Geriatric_Medicine_Internal_Medicine Hematology Hematology_Oncology Hematology_Pathology Hospice_and_Palliative_Care Immunopathology In_Vivo_and_In_Vitro_Nuclear_Medicine Infectious_Disease Internal_Medicine Interventional_Cardiology Laboratory_Medicine Massage_Therapist Maternal_and_Fetal_Medicine Medical_Genetics Medical_Microbiology Medical_Toxicology Medical_Toxicology_Preventative_Medicine Midwife MOHS_Micrographic_Surgery Naturopath Neonatal_Perinatal_Medicine Neonatology Nephrology Neurodevelopmental_Disabilities Neurology Neurology_Psychiatry Neurology_Child Neuromusculoskeletal_Medicine Neuropathology Neuropsychologist Neuroradiology Non_Physician_Surgical_Assistant Nuclear_Cardiology Nuclear_Imaging_and_Therapy Nuclear_Medicine Nurse_Practitioner Nurse_Licensed_Practical Nutritionist Obstetrics_and_Gynecology Occupational_Medicine Occupational_Therapy Oncology Oncology_Gynecologic Oncology_Medical Ophthalmology Optometry Oral_Surgeon Otolaryngology Otolaryngology_Facial_Plastic_Surgery Otology_Neurotology Pain_Management Pathology_Laboratory_Medicine Pathology_Anatomic Pathology_Anatomic_Clinical Pathology_Chemical Pathology_Clinical Pathology_Forensic Pediatric_Allergy_Immunology Pediatric_Cardiology Pediatric_Critical_Care_Medicine Pediatric_Dermatology Pediatric_Emergency_Medicine Pediatric_Endocrinology Pediatric_Gastroenterology Pediatric_Hematology_Oncology Pediatric_Infectious_Diseases Pediatric_Intensive_Care Pediatric_Nephrology Pediatric_Otolaryngology Pediatric_Pathology Pediatric_Pulmonology Pediatric_Radiology Pediatric_Rheumatology Pediatric_Sports_Medicine Pediatric_Surgery Pediatric_Urology Pediatrics Physical_Medicine_Rehabilitation Physical_Therapist Physician Physician_Assistant Podiatrist Preventive_Medicine_Occupational_EV Preventative_Medicine_Aerospace_Medicine Preventive_Medicine_Occupational Preventive_Medicine_Public_Health Proctology Public_Health_General_Preventive_Medicine Pulmonary_Disease Radiation_Oncology Radiation_Therapy Radiological_Physics Radiology Radiology_Diagnostic Radiology_Nuclear Registered_Dietician Registered_Nurse_First_Assistant Registered_Nurse_Anesthetist Rehabilitation_Medicine Respiratory_Therapist Rheumatology Roentgenology Sleep_Medicine Speech_Pathologist Speech_Therapy Spinal_Cord_Injury_Medicine Sports_Medicine Sports_Medicine_Emergency_Medicine Sports_Medicine_Internal_Medicine Sports_Medicine_Rehabilitation Surgery Surgery_Colon_Rectal Surgery_General_Vascular Surgery_Hand Surgery_Hand_Plastic Surgery_Hand_Orthopedic Surgery_Head_and_Neck Surgery_Neurological Surgery_Obstetrics_Gynecology Surgery_Orthopedic Surgery_Plastic Surgery_Plastic_Reconstructive Surgery_Thoracic Surgery_Thoracic_Cardiovascular Surgery_Urological Surgical_Critical_Care Transplant_Hepatology Undersea_Medicine Urology Vascular_Interventional_Radiology Vascular_Neurology If your Specialty is not listed please call 1-800-353-1232.
*Type of Degree:		Select one of the following
*Applying as:		Primary Care Physician (PCP) Specialist Allied Health
*State Medical License was issued in:		Select one of the following Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
*Medical License Number:
CAQH Provider ID:
Please provide your service location and mailing address:
*Street Address:
*City:
*County:
*State:	Select one of the following Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
*Zip/Postal Code:	- (12345-6789)
*The Mailing Address is the same as different than the primary service location's address above.
*Street Address:
*City:
*State:	Select one of the following Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
*Zip/Postal Code:	- (12345-6789)
Please provide further details:
Hospital Affiliation(s):	Usage Percent Usage Percent Usage Percent Usage Percent Usage Percent