Sample Patient Termination Letter

Posted in Termination Letters

Physicians are dedicated to the health and well-being of their patients. In some cases, a physician must make a decision to end the doctor-patient relationship. A doctor may discharge a patient for a variety of reasons including a failure to keep appointments, refusing to pay a bill, or being uncooperative and not following medical advice. The physician must give the patient sufficient notice and ensure the decision does not violate legal or managed care plan agreements.

Format and Content
To prevent a claim of abandonment, a letter detailing the termination decision should be sent to the patient by certified mail with a return receipt requested. The patient termination letter format should include the specific reasons as to why the doctor no longer wishes to provide a patient with medical care. The letter should include the amount of time the physician is giving the patient to find another healthcare provider. If a patient is in need of ongoing care this should be stressed in the letter along with medication requirements. The doctor should direct the patient to healthcare resources and inform the patient of the procedures regarding his or her medical records.

This patient termination letter sample is written by a physician who has decided to end the doctor-patient relationship based on a failure to keep appointments and to pay for the medical services provided. The reasons given are nondiscriminatory and can be backed up by documentation in the patient’s file.

June 5, 2013
Dr. Tom Varyaman
Inglewood Healthcare Associates
200 Fair Park Lane
Inglewood, TX 78547
Ms. Nancy Daniel
120 Arlington Street
Inglewood, TX 78547
Dear Ms. Daniel,
This letter is to inform you that I will no longer assume responsibility as your physician. I am terminating our physician-patient relationship based on numerous missed appointments and your continued failure to pay for the medical services provided. I will continue to provide medical services to you for 15 days following the date of this letter. I will provide emergency care for you for 30 days following the date of this letter. To prevent any misunderstanding, I am detailing the reasons for my decision below.
According to our records, you have failed to cancel or to show up for 6 appointments in the last 3 months. Our office policy is to charge patients a fee of $50 for every missed appointment that is not canceled within 24 hours of the appointment time. We have your signed acknowledgment of this policy on file. My office manager waived this fee for the appointments you missed on March 5, April 20, and May 10. You will be charged $150 on your final bill for the other 3 missed appointments.
Our office policy states a patient is responsible for payment on the date medical services are provided. Our records indicate you have an outstanding balance of $629.32. This amount includes medical treatment provided on November 13, 2012, November 28, 2012, and January 5, 2013 as well as the missed appointment fees. My office manager has sent you repeated requests for payment of your outstanding balance. A copy of your outstanding balance, itemized according to the treatment and date, is included with this letter.
I strongly encourage you to contact the county medical association for a physician referral. We will be happy to send copies of your medical records to your new physician. In order to release your medical records we will need a request from you in writing. I am enclosing a copy of the medical release form for your convenience. I wish you continued good health in the future.
Tom Varyaman
Dr. Tom Varyaman, M.D.
Medical Bills
Medical Release Form
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