Form Mo-15-04-69 - Credentialing Application Request Form Page 2
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1
2Aetna Better Health® of Missouri
Practitioner credentialing request form
Thank you for your interest in Aetna Better Health of Missouri. Please complete this form and send to Aetna
Better Health of Missouri Provider Relations Department by fax at 1-866-278-9981 or email at
. Please note: this form is only to be used for practitioners and must be
completed for each practitioner within the practice.
Section I: Practitioner Demographic Information
Practice Name
______________________
_____
Practice TIN
_____________ _____
_ Practice NPI
Practitioner Name (Last/First/MI)
__________________________
Degree
_____
SSN
DOB
_ Practitioner NPI
_____ _____________
Location Address
City/State/Zip
______
Phone ___________________ Fax _______________________ E-mail
___________________
Additional Locations: Yes No (If yes, please list additional addresses on a separate page.)
Section II: Practitioner Credentialing Information
Practitioner CAQH ID Number
Credentialing Address
City/State/Zip
Contact Name
_____________________
Title
______________________
Phone ____________________ Fax
__________________ E-mail
__________________________
If credentialing information obtained from other sources varies substantially from that provided by the
practitioner, Aetna Better Health of Missouri will notify the practitioner of the discrepancy in writing and provide
at least 30 days for the practitioner to provide an explanation or provide corrected information.
Section III: Practitioner Participation Information
Practitioner Type PCP
Specialist
Nurse Practitioner*
Specialty
*If the nurse practitioner is not going to act as a PCP or bill for services under his/her own name he/she will not be
credentialed and this form should not be completed. Nurse practicioners are required by Aetna Better Health of Missouri to
have a collaborative agreement with a Par Aetna Better Health of Missouri Physician. Please include a copy of that agreement
with this form.
Date:
____________ Completed By:
__________________________
Page 2 of 2
Aetna Better Health of Missouri Public Domain Use
Revised: 9/04/2015
MO-15-04-69
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