DOCUMENT OVERVIEW: This document may be used as a tool in reimbursement negotiations between practices and participating insurance companies.


[inside address]

Dear [name]:

We consider payment to be the responsibility of the patient in the patient–physician relationship. As you have ignored repeated requests to make payment, we can only assume you do not wish to honor your part of the relationship.

After numerous attempst to facilitate payment, we reget to inform you that we will be terminating your medical services with us as of [date] if we do not receive payment in full

Several options are open to you for medical care, including the hospital emergency department. We will be happy to forward your medical records to the physician of your choice on receipt of a properly signed release.



This document is provided to you as a courtesy by PGM Billing, a full service medical billing company.

This document is free to use it for personal or office use; however, may not be reproduced, transferred, sold, used for financial gain, or circulated in the public domain, without prior written authorization from

PGM Billing.