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DOCUMENT OVERVIEW : This document may be used as a tool in reimbursement negotiations between practices and participating insurance companies.

[date]

[inside address]

Dear[name]:

The principals of [name of practice] have met to discuss the group’s continued participation with [name of insurance company].

It is our consensus that [name of practice] can no longer continue to participate with [name of insurance company] under the current reimbursement schedule. While we beilieve this is unfortunate for all parties, to do so will ultimately jeopardize the quality-of-care standards that [name of practice] has established.

If [name of insurance company] is interested in discussing the above matter, please contact me at [telephone number].

Otherwise, this letter will serve as official notice of the cancellation of our participation agreement with [name of insurance company] effective [date]. After this date, we will be happy to see [name of insurance company] patients out-of-network.

Sincerely,

[name], MD

This document is provided to you as a courtesy by PGM Billing, a full service medical billing company.

This document is free to use it for personal or office use; however, may not be reproduced, transferred, sold, used for financial gain, or circulated in the public domain, without prior written authorization from

PGM Billing.