This form should be completed only by facility/ancillary provider groups and sole practitioners who do not 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	Provider Type: * Select Sole Practitioner Group Please enter Provider Type
Specialty: * Please enter Specialty	Number of Practitioners: * Please enter Number of Practioners
Tax ID: * Please enter Tax ID	NPI: * Please enter NPI
PA Medicaid Certified:      Yes      No	PA PROMISe ID: * Please enter PromiseID
Street: * Please enter Street	Suite:
City: * Please enter City	State: * Please enter State
ZIP: * Please enter ZipCode
Contact Name: * Please enter valid contact name	Contact Number: * Please enter valid phone number
Contact Email: * Please enter valid email	Contact Fax: * 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."