Patient Termination Letter

July 24, 2015

Use this form to terminate the physician/patient relationship. However, be sure to also check with your malpractice carrier to see if it has its own suggested termination letter.

To download this letter, click here: Patient Termination Letter


Date

Jane Doe
1234 Main
Anywhere, TX 12345

Dear Ms. Doe:

I am sorry to have to notify you of our intent to sever the patient-physician relationship between you and Dr. _______, effective ________, 200_. Between now and ______, 200_ we will provide emergency care only through the local hospital of your choice. During that time, you will need to secure the services of another physician to whom we will forward your records upon written request. Another physician may be located by contacting the ______________. [County Medical Society Referral service, and/or Hospital Referral Service]

I am enclosing a form that you will need to complete authorizing us to transfer your records to the physician you choose to take over care.

Sincerely,

_________________


To download this letter, click here: Patient Termination Letter

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