Microsoft Word - ECS LOA Example with signature
Date:ExamWorks Compliance Solutions1424 North Brown Road Suite 100Lawrenceville, GA 30043Re: Authorization for ExamWorks Compliance Solutions for Medicare Secondary Payer Recovery CasesDear ExamWorks Compliance Solutions:This letter confirms [Insert Parent Company Name](Insert Subsidiary Name here) has retained ExamWorks Compliance Solutions to work on its behalf to address any Medicare Secondary Payer recovery claim asserted against [Insert Parent Company Name](Insert Subsidiary Name here). ExamWorks Compliance Solutions may take any action that [Insert Parent Company Name](Insert Subsidiary Name here) would otherwise be entitled to take. ExamWorks Compliance Solutions has this authority for five years from the date of this letter or until [Insert Parent Company Name](Insert Subsidiary Name here) specifically revokes this authority in writing.Sincerely,546735411400Representative Signature63515684500Representative Name6351079500Representative Title63517081500Representative Address25401623400Representative Phone Number ................
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