UR Agent Letterhead

DATE

Dear (Ordering Practitioner):

Pursuant to the Massachusetts Department of Industrial Accidents Office of Health Policy, licensed personnel involved in the utilization review process, including the medical director, must be in active practice at least eight (8) hours per week. Please sign and date the form below and return it to (UR Agent) at the address noted on this letter.

Thank you,

 

UR Agent Name/Title

 

I, (Practitioner Name), am a (job title) in good standing, licensed to practice in the state of (state). I am currently in active practice at least eight (8) hours per week, practicing in the field in which I am duly licensed. I agree to notify (UR Agent) of any change in the status of my active practice.

 

______________________________­­­­_­ ­ _____________________________
Practitioner Name and Title Date