Sample Letter For Physicians Who Work In A Private Practice Setting printable pdf download

Sample Letter For Physicians Who Work In A Private Practice Setting

– SAMPLE LETTER –

For physicians who work in a private practice setting

Letter Must be Typed on Appropriate Letterhead

Date

National Board of Echocardiography, Inc.

1500 Sunday Drive, Suite 102

Raleigh, NC 27607

Physician’s Full Name

RE:

Physician’s Date of Birth

Physician’s Social Security Number

To Whom It May Concern:

This letter serves to confirm that Dr. _______(name) is a practicing cardiologist in private practice. Our records indicate that

____(he/she)____ has performed and interpreted echoes as follows:

2012

2013

2014

Transthoracic (93303-93308) *

####

Transesophageal (93312-93317)*

####

Stress Echo (93350)*

####

 I certify that the number of studies provided above are exact numbers and are not rounded and/or estimates.

(Please check box.)

Sincerely,

(signature)

Name

Title (President, CEO, or Business Manager)

Notary Seal

Sworn and subscribed to before me on (date): ___________________________

_______________________________________________________________

Signature of Notary Public

*NOTE: For the purpose of Certification, a study performed and/or interpreted may be counted only once and must be

counted under the code that it was billed. Example: Even though a full TTE is performed as part of a Stress Echo with only a

single bill being submitted (93350), the study must be counted as a Stress Echo and cannot be counted as both a TTE and a

Stress.

The EXACT number of studies performed and interpreted must be provided. Applications containing approximated and/or

rounded numbers will NOT be reviewed by the Certification Committee. Letters documenting level of service MUST be on

appropriate letterhead and MUST BE NOTARIZED.Note: The numbers provided must be in parallel, consecutive years, but

need not be calendar years. The end of the most recent year for which credit is requested must fall within the 12-months prior

to receipt of the complete application.

Sample Letter For Physicians Who Work In A Private Practice Setting