Dear [Physician's Name], I hope this letter finds you well. I am writing to inform you of my decision to terminate our physician-patient relationship. After careful consideration and evaluation of my healthcare needs, I have decided to seek medical care from another provider. Let me express my gratitude for the care and attention you have provided me during our time together. It is important for me to acknowledge that our relationship has been professional and respectful, and I appreciate the expertise and knowledge you have shared with me. However, due to various personal reasons [if applicable, briefly state the reasons for the termination e.g., relocation, change in insurance coverage, dissatisfaction with the treatment plan, etc.], I believe it is in my best interest to seek healthcare services from a different physician. I understand the significance of a continuous and consistent medical history; therefore, I kindly request that you provide a copy of my medical records to my new healthcare provider. This will ensure a seamless transition and allow for appropriate follow-up care. Please provide the records to the following address [include the address of the new provider or indicate where they should be sent]. To ensure compliance with relevant regulations, I expect that you will maintain the confidentiality of my medical information and handle the transfer of my records in a timely manner. While discontinuing our physician-patient relationship, I want to express my appreciation for the care I have received from your esteemed practice. The expertise and compassion shown by you and your team have contributed positively to my health journey. Thank you for your attention to this matter. I request that you acknowledge this letter and its content to acknowledge our physician-patient relationship's termination. If there are any administrative steps that I need to take, or if you require any further information, please do not hesitate to contact me at [provide contact details]. Wishing you continued success in your medical practice. Sincerely, [Your Name]
Para su conveniencia, debajo del texto en español le brindamos la versión completa de este formulario en inglés. For your convenience, the complete English version of this form is attached below the Spanish version.