VHAN Provider Update Form
Practice Name
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Practice Tax ID Number
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Last Name
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First Name
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Middle Initial
Degree
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Specialty
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NPI
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Please confirm that you have notified Aetna of your provider demographic updates, e.g. add, terms, locations, etc. via Aetna.com and please confirm the date you submitted these changes. We cannot attach your providers to Vanderbilt's Health Affiliated Network Tier until these demographic changes have been requested and made with the payor.
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Date changes were submitted to Aetna:
Servicing Location Address (List All)
Primary Practice Location
Supervising Physician (If Applicable)
Provider Email Address
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Start Date
Term Date
Is provider fulltime, part-time, PRN, coverage only, or locum tenens?
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Is the provider accepting new patients (able to schedule within 2 weeks)?
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Credentialing Contact Name
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Credentialing Contact Email Address
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