Sample Letter
For physicians who work in a hospital setting.
Copy and paste the sample text below to create a letter documenting your level of service (replacing bold text appropriately):

---

Date

National Board of Echocardiography
1500 Sunday Drive, Suite 102
Raleigh, NC 27607

To Whom It May Concern:

RE:	Doctor's Full Name
	Doctor's Date of Birth
	Doctor's Social Security Number

This letter serves to confirm that Dr. ____Name__________is a practicing cardiologist working in our Echocardiography Lab. Our records indicate that he/she has performed and interpreted echoes as follows:

	2004	2005	2006
Transthoracic (93303-93308)*	####	####	####
Transesophageal ((93312-93317)*	####	####	####
Stress Echo (93350)*	####	####	####

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

Sincerely,

Name
Title (Medical Director)**

Sworn and subscribed to before me on

______________________________

______________________________
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.

** In the absence of a formal director of the echocardiography laboratory, the letter should be written by an appropriate supervising physician. If applicant is the Medical Director of the Echocardiography Laboratory, the letter should be from the Chief of Cardiology or the Chief of Staff of the Hospital.