Sample patient dismissal letters

March 17, 2021

Updated May 3, 2021

See related article Terminating patient relationships: How to dismiss without abandoning

When a physician decides to dismiss a patient, the patient should be notified in writing. The letter should be printed on office letterhead and sent by first-class mail and by certified mail with a return receipt requested.

The letters below are meant as general resources only. State requirements may dictate specific elements to include in termination letters and how letters should be sent. Consult your state medical board for guidance. A blank authorization to release medical records should be enclosed.

Termination letters should not be sent electronically, such as by email or through the patient portal. It is preferred to send notification more formally, with physically trackable evidence of delivery. Check your state guidelines for further definition on sending termination letters electronically.
 

Letter 1 — Termination of the physician/patient relationship

[Date]

To [patient name]

Please be advised that I will no longer be able to treat you as a patient. The termination of our physician/patient relationship will be effective in 30 days from the date of this letter. Your medical condition requires continuing physician supervision, and it is important that you select another physician as soon as possible.

Contact your health insurance company or the county medical society for the names of other physicians. Upon written authorization, a copy of your medical record will be sent to your new physician. A medical record release form is enclosed.

Sincerely,

[physician name]

 

Letter 2 — Confirmation of patient-terminated relationship

Date

To [patient name]

This letter is sent to confirm your decision to discontinue care with me. Your medical condition requires physician supervision, and it is important that you select another physi­cian as soon as possible. I will be available to you until [30 days from date of letter].

Please contact your health insurance plan or the county medical society for names of other physicians. Upon written authori­zation, I will provide a copy of your medical record to your new physician. A medical record release form is enclosed to expedite the process.

Sincerely,

[physician name]

 

Letter 3 — Non-payment notice

Date

To [patient name]

It has come to my attention that you have been sent several letters regarding your outstanding account with our practice. If there has been a problem or if you are unhappy with the care that you have received in this practice, please contact me to discuss the situation. You are important to us, and I hope we can resolve any issues you have.

My business manager is also available to discuss payment of your account or to set up payment arrangements if they are needed. Should we not hear from you within 30 days, it would be mutually beneficial to ter­minate the physician-patient relationship so that you may locate a new physician.

I hope that we will hear from you in the near future

Sincerely,

[physician name]

 

Letter 4 — Termination for non-payment

Date

To [patient name]

On [date], I sent you a letter requesting that you contact the business manager or me regarding any problems that may have occurred resulting in non-payment of your account. In the letter, I stated that it would be necessary to terminate our physician/patient relationship if we did not hear from you.

Since we have not heard from you, please be advised that I will no longer be able to treat you as a patient. The termina­tion of our relationship will be effective in 30 days from the date of this letter.

A release form for your medical records is enclosed. Please contact us with the name of your new physician so we may forward your records to his or her office. At that time, your account will be closed.

Sincerely,

[physician name]

 

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