Modifier 62 reimbursement agreement letter

Does someone have a sample letter of agreement between 2 providers for modifier 62 reimbursement? One of our workers compensation carriers is requesting this document to split reimbursement of 62.5% equally. If not, could the statement of letter be as simple as "Reimbursement for procedures billed with modifier 62 to be reimbursed at 62.5% equally between provider A and provider B"

Thank You

re: Modifier 62 reimbursement agreement letter

Wasn't aware this type of letter was necessary. Each provider should be billing modifier 62 (indicates the reduction) on their separate bills. Both surgeons should get 62.5% of the fee schedule. Ask the surgeons or their office mgr if they have any documented agreement when they work together. I doubt any document exists and you will probably have to create something from scratch. Still don't see the need. The modifier reduction is common place.

re: Modifier 62 reimbursement agreement letter

I agree, however, our local Special Funds (workers compensation - ny state) carrier states they need the letter to determine how to distribute reimbursement.
NY State workers compensation law states "If there is no agreement on file, then it is up to the carrier to decide on how to allocate their reimbursement". What the carrier is doing is reimbursing one of the providers and not the other due to no agreement on file. They are the only carrier that does this.
Thank you for your input, just curious if anyone has encountered this before.