Patient Dismissal Letter Template printable pdf download

Patient Dismissal Letter Template

Date

Dear ______________:

As we discussed, you have failed to keep your last four scheduled office visits. In light

of this, I can no longer continue to assume responsibility as your physician. Therefore,

effective 31 days from the date of this letter, I will consider our physician-patient

relationship terminated.

I will continue to provide routine medical care for fifteen days from the date of this

letter, and I will provide emergency care for thirty days from the date of this letter. I

strongly recommend that you continue to receive healthcare and that you contact the

county medical association for a referral if you do not have clinician in mind.

My office will send copies of our medical records regarding the care we have provided

for you to another physician or health care organization once we receive a written

request from you to do so.

______________________ (Signature)

Return receipt requested

cc: File

Note: Highlighted portion can be adjusted to address your specific issue addressed with the

patient.

Note: Ask your professional liability carrier for review and approval before sending this letter.

Patient Dismissal Letter Template