Payer Termination Letter

November 16, 2017

Use this form to terminate the physician/payer relationship.




Payer Name
Payer Address
City, State, Zip


Via Facsimile: ____________ [fax number] (Hard Copy to Follow by Registered Mail)


To Whom It May Concern:


Pursuant to Section ___, Paragraph ___ of the Participating Medical Group Specialist Physician Agreement between ______________________________ [payer name] and __________________________ [practice or physician name], this letter serves as sufficient notice by __________________________ [practice or physician name] of its termination of the aforementioned agreement. This termination shall be become effective _________________.



Office Administrator or Physician


To download this letter, click here: Payer Termination Letter

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