NOTICE OF ENDING OUR PATIENT-CLINICIAN RELATIONSHIP

[Practice name]
[Practice address and phone]

[Date of letter]

PERSONAL AND CONFIDENTIAL
[Patient's full name]
[Mailing address on file]

Dear [Patient name],

I am writing to let you know that I will no longer be your [physician, nurse practitioner, or other role] after [end date, with the weekday]. This applies to [me only, or every clinician at the practice, named here].

WHY
[One or two neutral, factual sentences: what happened, when, and the date of any earlier warning. Delete this section where your regulator doesn't require a reason and you choose not to give one.]

YOUR CARE UNTIL [END DATE]
I will keep providing your care until [end date], urgent appointments included.
Appointments: [How to book, and any arrangement, such as phone or video visits only]
Prescriptions: [Which regular medicines are renewed, and the date they will last until]
Results and referrals: [Who follows up pending tests and referrals, and where reports will go]
Emergencies: At any time, call [emergency number] or go to the nearest emergency department.

FINDING A NEW CLINICIAN
[Where to look, such as a find-a-doctor service, a list of nearby practices taking new patients, or your health plan's directory]
[Any help the practice will give, such as sending a summary once you register]

YOUR MEDICAL RECORDS
[How a new clinician asks for them with your signed consent, how to get a copy yourself, any fee, and how long it takes]
[Enclosed: records release form, or delete this line]

[Closing line, such as: I wish you well with your future care.]

[Your name, credentials]
[License or registration number]
[Signature]

Sent by: [Tracked mail with a signature, such as certified or registered mail, plus regular mail or the patient portal] on [date sent]
Copy to: [Patient's chart, and anyone your agreements require you to tell]