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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.

1 Please provide the following information:

*:
*:
:
*: / /
(12/31/2006)
*:
(example@sample.com)
*: - -
(000-123-4567)
*: - -
(000-123-4567)
*: -
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.
*:
If your Specialty is not listed please call 1-800-353-1232.
*:
*: Primary Care Physician (PCP)
Specialist
Allied Health
*:
*:
:

2 Please provide your service location and mailing address:

*:
*:
*:
*:
*: -
(12345-6789)

*The Mailing Address is the primary service location's address above.

*:
*:
*:
*: -
(12345-6789)

3 Please provide further details:

: Usage Percent
Usage Percent
Usage Percent
Usage Percent
Usage Percent


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