Out-of-Network Exception Request Letter PDF

Request an in-network gap exception with provider details, urgency, and an attachments checklist.

Gap exception request details

All fields are optional. Include provider and urgency details to support the request.

Status message placeholder

Policyholder Name

Address

Insurance Company

Policy Number

Member ID

Patient Name (if different)

Requested Provider / Facility

Provider NPI

Service Requested

Reason In-Network Not Available

Time Sensitivity / Urgency

Requested Resolution

Generates a formal gap exception request with an attachments checklist.

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