This form is a sample letter in Word format covering the subject matter of the title of the form.
Dear [Physician's Name], I hope this letter finds you well. I am writing to inform you that I have made the decision to terminate our physician-patient relationship, effective [termination date]. First and foremost, I would like to express my appreciation for the care and attention you have provided me over the past [duration of the relationship]. I acknowledge and value the expertise and dedication you have shown throughout our time together. However, after thorough consideration and consultation with other medical professionals, I believe it is in my best interest to seek alternative healthcare options. This decision is not a reflection of your medical skills, but rather a personal choice based on my evolving healthcare needs and priorities. Living in Fairfax, Virginia, I am fortunate to have access to a wide range of exceptional healthcare providers and specialized medical centers. Given my specific health requirements, I have chosen to explore additional medical providers who may offer different perspectives, treatments, or specialized care that align more closely with my current situation. I understand the importance of continuity of care and the need for an orderly transfer of medical records. Therefore, I kindly request that you prepare and provide me with a copy of my comprehensive medical records, including any pertinent notes, test results, X-rays, MRI scans, lab reports, and medication history. If possible, I would greatly appreciate your assistance in facilitating the transfer of these records to my new healthcare provider. Please inform me of any procedures or paperwork required from my end to ensure a smooth transition. I will follow up with your office to retrieve these records at your earliest convenience. If there are any fees associated with copying or transferring these records, kindly let me know in advance. I genuinely appreciate the care and attention you have provided me during our time together. Your professionalism and compassion have always been evident, and I am grateful for the support you have offered. Thank you for your understanding and cooperation in this matter. Should circumstances change in the future, I would not hesitate to consider reestablishing our physician-patient relationship. Wishing you continued success in your medical practice. Sincerely, [Your Name]
Dear [Physician's Name], I hope this letter finds you well. I am writing to inform you that I have made the decision to terminate our physician-patient relationship, effective [termination date]. First and foremost, I would like to express my appreciation for the care and attention you have provided me over the past [duration of the relationship]. I acknowledge and value the expertise and dedication you have shown throughout our time together. However, after thorough consideration and consultation with other medical professionals, I believe it is in my best interest to seek alternative healthcare options. This decision is not a reflection of your medical skills, but rather a personal choice based on my evolving healthcare needs and priorities. Living in Fairfax, Virginia, I am fortunate to have access to a wide range of exceptional healthcare providers and specialized medical centers. Given my specific health requirements, I have chosen to explore additional medical providers who may offer different perspectives, treatments, or specialized care that align more closely with my current situation. I understand the importance of continuity of care and the need for an orderly transfer of medical records. Therefore, I kindly request that you prepare and provide me with a copy of my comprehensive medical records, including any pertinent notes, test results, X-rays, MRI scans, lab reports, and medication history. If possible, I would greatly appreciate your assistance in facilitating the transfer of these records to my new healthcare provider. Please inform me of any procedures or paperwork required from my end to ensure a smooth transition. I will follow up with your office to retrieve these records at your earliest convenience. If there are any fees associated with copying or transferring these records, kindly let me know in advance. I genuinely appreciate the care and attention you have provided me during our time together. Your professionalism and compassion have always been evident, and I am grateful for the support you have offered. Thank you for your understanding and cooperation in this matter. Should circumstances change in the future, I would not hesitate to consider reestablishing our physician-patient relationship. Wishing you continued success in your medical practice. Sincerely, [Your Name]