Initial Provider Application Network Role - Aetna

1 Network Role Initial Provider Application PCP. Allied Specialist Both Please include all forms and attachments upon return. Provider Information - Please check the box if additional information is attached (Please type or print). Name - Last First Middle (Jr., Sr., etc.) Any Prior Names Degree Birthdate (mm/dd/yyyy) Social Security Number UPIN Are you eligible to lawfully Language(s) Spoken By Language(s) Spoken In Office Practitioner work in the Yes No Aetna Participating Group Name: (If applicable) E-Mail Address Group Address - Number and Street Telephone Number Group TIN County Building/ Box City State ZIP Code Office Locations Primary Office Address - Number and Street Building/ Box City State ZIP Code Main Telephone Number FAX Number Handicap Access TIN TIN Owner (Appears on SS4 or W-9). Second Office Address - Number and Street Building/ Box City State ZIP Code Main Telephone Number Fax Number Handicap Access TIN TIN Owner (Appears on SS4 or W-9). Billing Address - Number and Street Building/ Box City State ZIP Code Main Telephone Number Fax Number Mailing Address - Number and Street Building/ Box City State ZIP Code Main Telephone Number Fax Number GR-67288-22 (2-03) 1 of 8.

2 Provider Name Date Primary Specialty Board Certification Yes No Name of Specialty Board Current Cert Expiration Date Additional Specialty Board Certification Name of Specialty Board Current Cert Expiration Date Yes No Additional Specialty Board Certification Name of Specialty Board Current Cert Expiration Date Yes No Education/Clinical Training - If additional information, attach on a separate sheet and check this box. College Name Specialty Track Degree City State/Country Attendance Dates Medical School and/or Applicable Graduate/Clinical Education Specialty Track Degree City State/Country Attendance Dates Post-graduate Education Specialty Track Name of Institution Internship Fellowship Residency Other City State/Country Attendance Dates License Information - Include State, Medical, Operating, DEA, CDS if required by state law License Type State License Number Issue Date Expiration Date DEA. CDS. State Medical/Operating State Medical/Operating State Medical/Operating Hospital Privileges Hospital Name City/State Admit Priv Privilege Status Est.

3 % of Hosp. Base (Y or N) Care Active/ Courtesy Provisional Temp Allied Full Consult 2 of 8. Provider Name Date If you do not have admitting privileges, include documentation of your formal coverage arrangement. Chief of Department: New Graduates: Include Director of Residency Program Primary Hospital Name: Name: Name: Address: Address: City/State/ZIP: City/State/ZIP: Telephone Number: Telephone Number: Patient Coverage Please Type or Print. If additional information, attach on separate sheet and check this box. Physicians: 24 hour, 7 day a week coverage is required. Covering physician must participate with Aetna . Coverage for your patients is provided in your absence by Name Aetna Provider Specialty Telephone Number Address - Number and Street Building Suite City State ZIP Code Name Aetna Provider Specialty Telephone Number Address - Number and Street Building Suite City State ZIP Code Insurance - Professional Liability Name of Current Professional Liability Insurance Carrier City State Telephone Number Policy Number Policy Expiration Date Liability Per Occurrence/Agg.

4 Amount Type $ $ Claims Made Occurrence Tail General Liability Name of Current General Liability Insurance Carrier City State Telephone Number Policy Number Policy Expiration Date Liability Per Occurrence/Agg. Amount Type $ $ Claims Made Occurrence Tail Work History (Most Recent 5 years) If additional information, attach on separate sheet and check this box. From Present/ Corporate/Practice Name Position in Practice Address - Number and Street City State/ZIP. To Year 3 of 8. Provider Name Date Provider Information - Please check the box if additional information is attached If physician is part of a group practice, all physicians in the group must meet participation criteria and must agree to participate in all Company plans. If all physicians in the group do not meet these criteria, the group cannot participate. Note: (All members of a group must participate with Aetna ). Office Hours: What are your scheduled ( posted hours for scheduled patients) office hours? Primary Office - Scheduled Office Hours Second Office - Scheduled Office Hours Day(s) Evening Day(s) Evening Monday Monday Tuesday Tuesday Wednesday Wednesday Thursday Thursday Friday Friday Saturday Saturday Sunday Sunday Panel Information Accepting New Patients Is there an assistant present in your office during regularly scheduled hours?

5 Yes No Yes No Standard Aetna Standard Meets Standard If No - Your Standard Immediately (Or referral to ER. Scheduling Time for Emergency Care as appropriate) Yes No Scheduling Time for Urgent Care Same day or within 24 hours Yes No Scheduling Time for Symptomatic Care ( , sore throat) Within 72 hours Yes No Scheduling Time for Routine Visits ( , blood pressure check) Within 7 days Yes No Scheduling Time for Preventive Routine Care ( , school physical, annual physical) Within 30 days Yes No Maximum Number of Intermediate/ Limited 4 - 5 Per hour Appointments Per Hour (6 per hour for Ped) Yes No Waiting Time in the Office (From Time of Scheduled Appointment to Examination) < 30 minutes Yes No Response Time for returning Patient Call Within 45 minutes Yes No Does your office employ paraprofessionals ( , nurse practitioners or Pas) for direct patient care? Yes No Do you limit age or type of patients you see? Yes No Choose the age limitations (as many as appropriate) your practice prefers.

6 (Must have admitting privileges and training for appropriate ages selected.). Pediatrics Pediatrics Internal Medicine Internal Medicine Family Practice Adolescent Medicine General Practice Newborn through Newborn through Ages 12 through Newborn through Ages 13 through Newborn through 21 years 21 years geriatrics geriatrics 21 years geriatrics Geriatrics Other Patient Age and over. Please specify: Have you had a full explanation by Aetna representative of the applicable compensation system? Yes No Do you agree to comply with Aetna 's policy on confidentiality and members' rights and responsibilities as detailed in your contract? Yes No 4 of 8. Provider Name Date Do you understand that, subject to proper confidentiality restrictions and authorization, your office medical records will be subject to inspection by Aetna representatives for peer, quality and utilization review purposes? Yes No Does your practice participate in a residency training program in which residents provide care for patients in your office?

7 Yes No Does your office employ paraprofessionals ( , nurse practitioners or PAs) for direct patient care? Yes No If Yes, are your patients informed? Yes No If Yes, are your patients extended the option to see the physician? Yes No If Yes, do you maintain their current credentials, licenses and malpractice information? Yes No If Yes, do you credential: Annually Biennially If Yes, do you allow patients to be cared for by paraprofessionals when you or your associates are not in the office? Yes No If Yes, how many paraprofessionals and what are their types? ( , PA, NP, etc.). 5 of 8. Confidential Information Provider Name TIN Date Instructions The information requested on this form will be used in the Aetna credentialing process. The questions are intentionally worded to solicit as much information as possible for review and consideration. It is important that the information you provide be as complete and accurate as possible because any misstatement or omission of relevant information will constitute grounds for rejection of your Application or summary dismissal as a participating Provider .

8 Thus, it is better to err on the side of inclusion with appropriate explanation, rather than exclusion. In addition, you will be held responsible for all statements written in the Application , regardless of whether such statements were prepared by you or by an employee, agent or representative. Definitions: As used in this section of the Application , the following terms are defined as follows: Ability to practice medicine is to be construed to include all of the following: a. The cognitive capacity to make appropriate clinical diagnoses and exercise reasonable medical judgments and to learn to keep abreast of medical developments; including but not limited to: diagnosis and treatment of patients; referral of patients to other appropriate providers; prescribing appropriate medications and other substances for patients; maintaining and reviewing patients'. charts and providing coverage for patients. b. The ability to communicate those judgments and medical information to patients and other health care providers, with or without the use of aids or devices such as voice amplifiers; and c.

9 The physical capability to perform medical tasks such as physical examination and surgical procedures, with or without the use of aids or devices such as corrective lenses or hearing aids. d. The provisions for administrative review of cases for appropriateness or conducting peer review. Adverse action includes, but is not limited to, the following or their substantial equivalents (regardless of any subsequent action or expungement of the record): staff privileges reduced, withheld, suspended, voluntarily surrendered, resigned, revoked or subject to any special provisions; denial; restrictions; fine; counseling; monitoring; medical or psychological evaluation; probation; loss in whole or part; suspension; termination or refused participation; letter of concern, guidance, censure, or reprimand; administrative letter, expiration without renewal; nonrenewal; subjected to disciplinary action or other similar action or other limitation; voluntary or involuntary surrender of licensure or status to avoid or in anticipation of any of the adverse actions listed, regardless of whether said action is or may be reportable to the National Practitioner Data Bank or any other officially sanctioned or required registry.

10 Chemical substances is to be construed to include alcohol, drugs or medications, including those taken pursuant to a valid prescription for legitimate medical purposes and in accordance with the prescriber's direction, as well as those used illegally. Convicted of a crime includes a finding of guilt by a judge or jury, a plea of guilty or non contendre plea, participation in a first offender program or any other such program which may be available as an alternative to proceeding with prosecution, whether or not the record has been closed or expunged. While a minor traffic offense is not considered convicted of a crime, DWI or DUI is not a minor traffic offense. Currently does not mean on the day of, or even in the weeks or months preceding, the completion of this Application . Rather, it means recently enough so that the use of chemical substances may have an ongoing impact on one's functioning as a licensee, or within the past two (2) years. Medical condition includes physiological, mental or psychological conditions or disorders such as but not limited to orthopedic, visual, speech and hearing impairments, cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, mental retardation, emotional or mental illness, specific learning disabilities, HIV disease, tuberculosis, drug addiction or alcoholism.