Get Aetna Initial Provider Application Form 2017-2025

The Aetna Initial Provider Application Form is a crucial document for healthcare providers seeking participation within the Aetna network. This guide provides clear, step-by-step instructions on completing this form online, ensuring a smooth application process.

Follow the steps to fill out the Aetna Initial Provider Application Form with ease.

1. Press the 'Get Form' button to access the application and open it for completion.
2. Section one requires you to indicate your network role by selecting either PCP, Specialist, Both, or Allied. Ensure that you check the appropriate box.
3. In the Provider Information section, provide your last name, first name, middle name (including any suffixes such as Jr. or Sr.) and any prior names if applicable.
4. Fill in your degree, birthdate in the format of mm/dd/yyyy, Social Security number, and UPIN, if applicable. Confirm that you are eligible to work in the U.S. by selecting 'Yes' or 'No'.
5. List the languages you speak, both personally and in your office setting, to facilitate effective communication.
6. If applicable, provide the name of your Aetna participating group, along with your email address and group address, including telephone number and TIN.
7. Complete the office locations section by detailing your primary office address, telephone number, and fax number. Include information about handicap access if available.
8. Provide details of any secondary office addresses as necessary, following the same format as in the primary office section.
9. Indicate your primary specialty and any additional specialties, along with board certification statuses and expiration dates.
10. Complete the education and clinical training section, detailing the institutions attended, specialties studied, and attendance dates.
11. Fill out your license information, including type, state, license number, issue date, and expiration date. Ensure all required licenses are listed, such as DEA and CDS.
12. List your hospital privileges, including the name of the hospital, city and state, and admission privileges with corresponding status.
13. Detail your patient coverage arrangements, listing the name, specialty, and contact information of covering physicians.
14. Complete the insurance information section, providing details of your professional liability and general liability insurance carriers and policy information.
15. Document your work history over the past five years, noting corporate or practice names, positions held, and addresses.
16. Address the panel information by specifying if you are accepting new patients and detailing your office hours.
17. Respond to the questions regarding your professional practice, ensuring you provide complete and honest answers.
18. Carefully review the release and authorization section, ensuring you understand the implications of sharing your information.
19. Finally, attest that the information provided is correct and complete, and sign the document electronically.
20. Once you have completed all sections, save your changes, and consider downloading or printing the form for your records.

Complete your Aetna Initial Provider Application Form online today to ensure your application is submitted efficiently!