Nominate A Dentist
If you would like to nominate a dentist to apply for participation in the Vital Savings by Aetna®/Aetna Dental AccessSM network, please complete and submit this form. We will arrange to have the dentist contacted and invited to participate.

Completion of this form does not guarantee network participation. Applicants must complete Aetna's credentialing process and execute our participation agreement acceptable to Aetna prior to network participation.


Please provide the following information:
Name of Dental Office
Dentist Last Name*
Dentist First Name*
Dentist Middle Initial
Email Address*
i.e. example@sample.com
Street Address
 
City
State
Zip/Postal Code
County
Phone Number*
(include Area Code)
Contact name at dental office
Specialty
  
Please provide your contact information.  
                NameEmail
Have you told the dentist that you are making this referral? Yes        No
May we tell the dentist that you are the source of the referral? Yes        No
 
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