Louisiana Sample Letter for Termination of Physician's Care - Patient to Physician

• Category: Letters - Nonlegal - Termination
• State: Multi-State
• Control #: US-0237LR
• Format: Word; Rich Text

Description

This form is a sample letter in Word format covering the subject matter of the title of the form. Subject: Notice of Termination of Physician's Care — Patient to Physician: [Full Name of Patient] [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 inform you of my decision to terminate our patient-physician relationship, effectively immediately. It is with considerable thought and consideration that I have arrived at this conclusion. Please consider this letter as a formal notice of termination of our physician-patient relationship. As an individual who values healthcare greatly, I place utmost importance on the doctor-patient partnership. However, after prolonged contemplation and consulting with other medical professionals, I have decided that it is in my best interest to seek alternative medical care. This decision is final and non-negotiable. I would like to take a moment to express my gratitude for your medical expertise and the care provided to me during our time together. Nonetheless, due to personal reasons [if applicable, briefly state the reasons here without going into excessive detail], I am compelled to pursue alternative healthcare options. In light of the termination of our patient-physician relationship, please take the necessary actions to ensure the continuity of my medical records. I kindly request that you provide a complete copy of my medical records including, but not limited to, diagnoses, treatment plans, test results, and any clinical notes. I understand that there may be charges associated with this request, and I am more than willing to make the necessary payment for the provision of these records. Please provide the medical records in a format that adheres to the guidelines outlined in the Health Insurance Portability and Accountability Act (HIPAA) to ensure compliance with patient privacy and confidentiality protections. Additionally, I would greatly appreciate it if you could recommend a trusted healthcare provider in the same field of specialization to continue my care. Your professional guidance in this matter would be invaluable to me. Furthermore, please consider this letter as permission to disclose my medical records to my new healthcare provider once I have identified one. I will reach out to your office as soon as possible with the relevant details and contact information of my new physician. Lastly, I kindly request that you acknowledge this letter as well as its attachments, indicating your agreement with the termination of our physician-patient relationship. Please send this acknowledgement to the following address within fifteen (15) days of receiving this letter: [Patient's Name] [Patient's Address] [City, State, Zip] Should you require any further information or clarification, please do not hesitate to contact me at [Phone Number] or via email at [Email Address]. Thank you for your understanding and cooperation in this matter. I trust that you will ensure a smooth transition as I seek alternative medical care. Sincerely, [Full Name of Patient] [Patient's Address] [City, State, Zip]

Subject: Notice of Termination of Physician's Care — Patient to Physician: [Full Name of Patient] [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 inform you of my decision to terminate our patient-physician relationship, effectively immediately. It is with considerable thought and consideration that I have arrived at this conclusion. Please consider this letter as a formal notice of termination of our physician-patient relationship. As an individual who values healthcare greatly, I place utmost importance on the doctor-patient partnership. However, after prolonged contemplation and consulting with other medical professionals, I have decided that it is in my best interest to seek alternative medical care. This decision is final and non-negotiable. I would like to take a moment to express my gratitude for your medical expertise and the care provided to me during our time together. Nonetheless, due to personal reasons [if applicable, briefly state the reasons here without going into excessive detail], I am compelled to pursue alternative healthcare options. In light of the termination of our patient-physician relationship, please take the necessary actions to ensure the continuity of my medical records. I kindly request that you provide a complete copy of my medical records including, but not limited to, diagnoses, treatment plans, test results, and any clinical notes. I understand that there may be charges associated with this request, and I am more than willing to make the necessary payment for the provision of these records. Please provide the medical records in a format that adheres to the guidelines outlined in the Health Insurance Portability and Accountability Act (HIPAA) to ensure compliance with patient privacy and confidentiality protections. Additionally, I would greatly appreciate it if you could recommend a trusted healthcare provider in the same field of specialization to continue my care. Your professional guidance in this matter would be invaluable to me. Furthermore, please consider this letter as permission to disclose my medical records to my new healthcare provider once I have identified one. I will reach out to your office as soon as possible with the relevant details and contact information of my new physician. Lastly, I kindly request that you acknowledge this letter as well as its attachments, indicating your agreement with the termination of our physician-patient relationship. Please send this acknowledgement to the following address within fifteen (15) days of receiving this letter: [Patient's Name] [Patient's Address] [City, State, Zip] Should you require any further information or clarification, please do not hesitate to contact me at [Phone Number] or via email at [Email Address]. Thank you for your understanding and cooperation in this matter. I trust that you will ensure a smooth transition as I seek alternative medical care. Sincerely, [Full Name of Patient] [Patient's Address] [City, State, Zip]