Physician-Patient Relationship Termination Form
Complete this form to document the ending of a physician-patient relationship, including the reason for termination, care transition details, and acknowledgment of notice.
Physician's Full Name
*
First Name
Last Name
Practice or Clinic Name
*
Patient's Full Name
*
First Name
Last Name
Patient Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Termination Notice
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Effective Date of Termination
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Termination
*
Please Select
Failure to follow treatment recommendations
Repeated missed appointments
Non-payment for services
Inappropriate behavior
Relocation
Other
Details or Additional Comments (if any)
Recommended Next Steps or Referral Information
Acknowledgment of Receipt of Termination Notice
*
I acknowledge receipt and understanding of this notice
Submit
Should be Empty: