Termination of Care

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.