UR Agent Letterhead
Date:
RE:
Dear [Ordering Practitioner]:
Confirming our conversation on [ date ], you have requested that your appeal of the adverse determination regarding [ injured worker ] be withdrawn. If you wish to go forward with the appeal in the near future, please provide written notification by fax or mail within the thirty (30 ) day appeal period.
If you have any questions, please contact me at [ toll free number ].
Sincerely,
UR Agent Name/Title
CC: Injured Worker
Adjuster Name/Company