Request for participation Status

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.    
[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