Below is an example of a letter that you may include when requesting to register as an Out of Network practitioner with insurance carriers.

ATTENTION: Provider Relations Department 

All Commercial Third-Party Payers 

To Whom It May Concern: 

I am writing to update your database regarding my private practice details. I am an out-of-network (non-participating) practitioner. 

My private practice details are the following: 

My Name (as Rendering Provider): ____________________________________ 

Credentials/Degree:                           ________________________ 

My Individual NPI Number:               ________________________ 

Primary Practice Address:                  ____________________________________ 

                                                                _____________________, ____ _________ 

My Practice TaxID Number (EIN): ___________________________________ 

Type II NPI Number: 

Organization/Practice Name: _________________________________ 

Type II NPI Number: _________________________________ 


Establishment of Practice: 

All of the above practice details have been active for more than 12 months. 

In addition, my patients/clients pay for my services in full at the time of the appointment. 

All reimbursements for my services should be made directly to the insured party. 

Please adjust your provider database accordingly. Thank you for your attention to this matter. 




Today’s Date: ________________________ 

Office Telephone: _____________________ 

Office Email: _________________________