Dear (patient's name),

This letter is to inform you that I am no longer able to continue as your physician. (Here you may insert the basis for your decision to terminate services if you feel an explanation is necessary)

As you are aware, you are suffering from a condition that requires further medical attention. I recommend that you contact a physician to provide those services to you without delay. During the interim, but for no longer than 30 days from the date of this letter, I will continue to provide you with routine or emergency medical care.

At your request, I will provide, you or the physician you select, a copy of your complete medical record. Please sign and return to me the attached medical record authorization. If you have a problem selecting a physician, I suggest you contact the medical society for a list of physicians practicing in your local area.

Very truly yours,

(your name), M.D.

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