Patient Notification of Contract Termination

October 30, 2014

Sample letter to send to patients if practice terminates contract with a managed care plan.

To download this form, click here:  Letter to Patients RE Contract Termination.doc


Patient Name


City, State, Zip


Date: ____________


To all of our ____________ (Payer Name) Patients:

Effective ________________ (Date), the ___________ (Clinic Name) will discontinue its participating provider relationship with ____________ (Payer Name).  Until that day and beyond we will continue to care for you.

You may count on us to continue your care as we have cared for you in the past.  If after _________ (Date) ______________ (Payer Name) no longer desires to keep us in their provider network, please know that our clinic will make every effort to continue our professional relationship with you.

We will keep you informed if anything changes in our relationship with ______________ (Payer Name).  Feel free to talk to us about this or call your employer or your _____________ (Payer Name) representative.  Their number should be on the back of your insurance card. [Note: Insert specific rep name and phone number if you have it].

Of all the managed care companies with which we contract, ________________ (Payer Name) provides us reimbursement which is markedly below that of other insurance carriers for the medical services we provide our patients.  We believe that _________________ (Payer Name) is only willing to pay for standard care and is not willing to pay for superior care.  Data has been published that show our A1c, cholesterol and blood pressure control results surpass those published by the Cleveland Clinic. [Insert clinical outcomes here for your medical specialty – very important].

We believe that our clinic stands for superior health care and that it is our professional responsibility to maintain that standard.



The Physicians of __________________ (Clinic Name)


To download this form, click here:  Letter to Patients RE Contract Termination

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