VHAN Provider Update Form

VHAN Provider Update Form

Practice Name*

Practice Tax ID Number*

Last Name*

First Name*

Middle Initial

Degree*

Specialty*

NPI*

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.*

Select or enter value

Date changes were submitted to Aetna:

Servicing Location Address (List All)

Primary Practice Location

Supervising Physician (If Applicable)

Provider Email Address*

Start Date

Term Date

Is provider fulltime, part-time, PRN, coverage only, or locum tenens?*

Select or enter value

Is the provider accepting new patients (able to schedule within 2 weeks)?*

Select

Credentialing Contact Name*

Credentialing Contact Email Address*

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