SAMPLE LETTER TO STATE MEDICAL DIRECTOR

RE:        Nomination of pain physicians to serve on CAC to represent interventional pain management

Dear Dr. __________,

Regarding Publication 100-08 Medicare Program Integrity, Transmittal 106, Change Request 3721, Issued on March 4, 2005, making interventional pain management specialists the 34th specialty represented on the Carrier Advisory Committee, we are pleased to nominate (1st doctor) to serve as a Carrier Advisory Committee Member and (2nd doctor) to serve as an alternate member.

Our nominations are based on instructions in the CMS Program Integrity Manual, which specify that carriers select committee representatives from names recommended by state medical societies and specialty societies.  We submit our nominations on behalf of the (state society name).

[1st doctor ] is a physician of integrity and knowledge,  interested in the advancement of medicine.  (You can add any specifics you have on this person).  He is interested in serving on the Carrier Advisory Committee. 

[2nd doctor] is a physician of integrity and knowledge,  interested in the advancement of medicine.  (You can add any specifics you have on this person).  He is interested in serving on the Carrier Advisory Committee. 

If you have any further questions, please feel free to contact me [give your address, telephone, e-mail, etc.]

Thank you for your assistance in this matter.

____________________

Signature

TITLE

[State] Medical Society

American Society of Interventional Pain Physicians