SAMPLE LETTER #3
CERTIFIED MAIL
Jane No-Show
123 Sesame Street
Far-Away, MI 54321
Dear Ms. No-Show,
It has been recorded that you failed to show or cancel your appointments on [INSERT 1st DATE HERE], [INSERT 2nd DATE HERE] and [INSERT 3rd DATE HERE]. As stated in my previous letter dated, [INSERT DATE HERE], “office policy states that three no-call/no-shows on regularly scheduled appointments will lead to automatic termination of the doctor-patient relationship in this practice.”
I value my time as much as you, no doubt, value yours. Unfortunately, I believe that it would be in the best interest for us to terminate our professional relationship. I will continue to treat you on an emergency only basis from the date of this letter until [INSERT DATE AND TIME HERE].
The current status of your oral health is [INSERT STATUS HERE]. With this stated, you are in need of the following treatment: [INSERT TREATMENT HERE]. At this time, I strongly advise and encourage you to secure a dentist [TO INCLUDE ANY SPECIALISTS, PENDING TYPE OF TREATMENT NEEDED]. Following are a few of the many sources you can use to locate a new treating dentist:
1. the yellow pages, relatives and/or coworkers;
2. your insurance carrier or employer benefit representative;
3. your caseworker or the state’s Medicaid Hotline at (800) 642-3195 (Medicaid patients);
4. your PPO.
Please complete and return the enclosed release of records form when you have established a new providing dentist and would like your records transferred. It is office policy to charge a fee of [INSERT FEE HERE] for duplication of records. This fee should accompany the completed form when you return it.
If you have any questions or concerns, please feel free to call me at (000) 111-2222. Thank you.
Sincerely,
Dr. Smile [or HIS/HER DESIGNEE]
Enclosure (1)
c: Patient File