Section 401.APPENDIX D   Example Letter of Agreement for Radiologist Assistant

Technologist Accreditation Program

Illinois Emergency Management Agency

1035 Outer Park Dr.

Springfield IL  62704

Re:  (Name of Applicant)

To whom it may concern:

This letter is to serve as acknowledgement that (Name of Applicant) will be employed by (Name of Radiology Group or Facility) under my supervision.  (Name of Applicant) will, as a radiologist assistant, perform a variety of activities in the areas of patient care, patient management, clinical imaging and interventional procedures.  It is also recognized that (he/she) may not interpret images, make diagnosis or prescribe medications or therapies. 

I am a radiologist, licensed by the State of Illinois as a physician, and certified by the American Board of Radiology or the American Osteopathic Board of Radiology (select the appropriate Board).

Sincerely, 

Physician's Name (Typed)

(Source:  Added at 37 Ill. Reg. 14008, effective August 22, 2013)