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DOCUMENT OVERVIEW: Contracting with Insurance Companies will enhance your patient population and help grow your business. The below document may be used to request provider participation requirement information.

[date]

[inside address]

RE: Request for participation status

To Whom It May Concern:

My [specialty] practice will open [date] at [street address, city, state, zip code]. My state license number is [-].

I am requesting participating status in [name of insurance company]. Please send me the written requirements and any forms that need to be completed. Please call me at [telephone number] if you have any questions. Or e-mail me at [-] or send your response to [street address, city, state, zip code].

Kindest regards,

[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.