Use this form to terminate the physician/payer relationship.
_____________________
Date
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 _________________.
Respectfully,
____________________________
Office Administrator or Physician
To download this letter, click here: Payer Termination Letter
