DOCUMENT OVERVIEW: This document may be used as a tool in reimbursement negotiations
between practices and participating insurance companies.
[date]
[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.
Sincerely,
[name]