UR Agent Letterhead




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on [ date ], you have requested that your appeal of the adverse determination regarding [ injured worker ] be withdrawn.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 ].



UR Agent Name/Title

CC: Injured Worker
Adjuster Name/Company