[Your Name] [Your Address] [City, State, ZIP] [Email Address] [Phone Number] [Date] [Physician's Name] [Physician's Address] [City, State, ZIP] Dear Dr. [Physician's Last Name], I hope this letter finds you well. I am writing to formally terminate our physician-patient relationship effective immediately. After careful consideration and discussions with other healthcare professionals, I have decided to seek medical care elsewhere. Therefore, I kindly request that you transfer my medical records to the new healthcare provider as soon as possible. I would like to express my gratitude for the medical care you have provided me during our time together. Your expertise, professionalism, and dedication have been greatly appreciated. However, I believe it is in my best interest to explore alternative medical options to address my current healthcare needs. The decision to switch healthcare providers was not made lightly. I have carefully researched and discussed my medical concerns and treatment options with other specialists in the San Jose, California area. After thorough consideration, I have chosen to pursue a different course of treatment that aligns better with my personal healthcare goals and preferences. To ensure a smooth transition of care, I would appreciate it if you could prepare and promptly forward a copy of my complete medical records, including all relevant test results, diagnoses, treatment plans, and prescriptions, to the following address: [New Healthcare Provider's Name] [New Healthcare Provider's Address] [City, State, ZIP] Furthermore, if there are any outstanding bills or medical expenses that require my attention, kindly inform me promptly so that I can settle them accordingly. I value financial transparency and would like to ensure that all necessary settlements are made appropriately. I would like to stress that my decision to change healthcare providers is not a reflection of any dissatisfaction with your care or services. Furthermore, I have simply chosen to explore different avenues in addressing my healthcare needs. Furthermore, I appreciate the time and effort you have dedicated to my medical well-being and wish you continued success in your practice. Thank you for your understanding and cooperation in this matter. I kindly request a written confirmation of this termination letter, along with an acknowledgment that my medical records have been sent to the provided address. Should you require any further information or documentation, please do not hesitate to contact me. Wishing you all the best in your future endeavors. 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.