AETNA BETTER HEALTH® OF PENNSYLVANIA
Ancillary & Facility Request to Join Network Form
This form should be completed only by facility/ancillary provider groups and sole practitioners who do
have an existing agreement with ABH PA. Provider groups with an existing agreement who want to add practitioners to their agreement should reference the Practitioner Application. That application can be found at
Provider Application Form
Provider’s Legal Name:
Please enter Provider Name
Please enter Provider Type
Please enter Specialty
Number of Practitioners:
Please enter Number of Practioners
Please enter Tax ID
Please enter NPI
PA Medicaid Certified:
PA PROMISe ID:
Please enter PromiseID
Please enter Street
Please enter City
Please enter State
Please enter ZipCode
Please enter valid contact name
Please enter valid phone number
Please enter valid email
Please enter valid fax number
Your request will be reviewed and a decision will be made within 60 days.
If the panel is open and we intend to pursue a contract, a Network Manager will reach out to proceed with the formal credentialing and contracting process.
If the panel is not open or we do not intend to pursue a contract, a letter will be sent out advising that the request has been denied at this time.
Confidential: the above information is confidential and should be read only by the addressee or the addressee’s specific designees in accordance with the Aetna Code of Conduct and applicable law."