Since we have not heard from you, please be advised that I will no longer be able to treat you as a patient. In the letter, I stated that it would be necessary to terminate our physician/patient relationship if we did not hear from you. On, 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. I hope that we will hear from you in the near future 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. My business manager is also available to discuss payment of your account or to set up payment arrangements if they are needed. You are important to us, and I hope we can resolve any issues you have. 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. It has come to my attention that you have been sent several letters regarding your outstanding account with our practice. A medical record release form is enclosed to expedite the process. Upon written authorization, I will provide a copy of your medical record to your new physician. Please contact your health insurance plan or the county medical society for names of other physicians. Your medical condition requires physician supervision, and it is important that you select another physician as soon as possible. This letter is sent to confirm your decision to discontinue care with me. Letter 2 - Confirmation of patient-terminated relationship A medical record release form is enclosed. Upon written authorization, a copy of your medical record will be sent to your new physician. Your medical condition requires continuing physician supervision, and it is important that you select another physician as soon as possible.Ĭontact your health insurance company or the county medical society for the names of other physicians. The termination of our physician/patient relationship will be effective in 30 days from the date of this letter. Please be advised that I will no longer be able to treat you as a patient. Letter 1 - Termination of the physician/patient relationship Check your state guidelines for further definition on sending termination letters electronically. It is preferred to send notification more formally, with physically trackable evidence of delivery. Termination letters should not be sent electronically, such as by email or through the patient portal. A blank authorization to release medical records should be enclosed. Consult your state medical board for guidance. State requirements may dictate specific elements to include in termination letters and how letters should be sent. The letters below are meant as general resources only. The letter should be printed on office letterhead and sent by first-class mail and by certified mail with a return receipt requested. When a physician decides to dismiss a patient, the patient should be notified in writing. See related article Terminating patient relationships: How to dismiss without abandoning In addition to this letter, don't forget to attach a letter from your health care provider in support of your request.Texas Medical Liability Trust Resource Hub Find templates for self-funded plans here. The legal explanations can also be useful to appeal a denial of a preauthorization or claim request.Īs a reminder, if you have a self-funded plan, you should write your employer or school for preauthorization. The legal explanations will be particularly useful in cases where your plan has a blanket exclusion or an exclusion of a specific procedure. Instructions on how to complete the letter are on the first page of the document.īelow you can find the different paragraphs that you can copy into your letter under the "LEGAL EXPLANATION" section. Download: Template for writing your insurance company to get transition care preauthorized (.doc) On this page you can download a template for a letter to send to your insurance company requesting preauthorization, which you should fill in with your information.
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