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)