Patient Notice of Discontinuance of Care

SHCS P&P 170-13

Att. 2 Template Letter Patient Notice for Discontinuance of Care

Patient Notice of Discontinuance of Care

To be sent Certified Mail with Return Receipt Requested

[Date]

[Patient/Client Name]

[Address]

[City], [Zip]

Dear [Mr./Ms.] [ Patient/Client Last Name]:

Please be advised that as of [date no less than one month from date of letter] you are formally discharged from the UC Davis Student Health and Counseling Services (SHCS).

Specific reasons for this action follows: [Provide appropriate reasons, i.e., detail breakdown in provider-patient/client relationship, abusive behavior, etc.]. These actions have served to compromise the physician-patient/client relationship that is necessary to meet your health care needs.

Our attempts to resolve this issue with you include: [Document attempts you've made to counsel the patient/client and correct the problem, instances of the patient's/client’s non-compliance, refusal to cooperate, etc.]

Please be advised that the following health care risks may occur should you choose not to seek continued care with a new physician:

[Insert any significant health risks faced by the patient/client if he or she does not seek continued care. Be sure to include any specific instructions necessary for managing the patient's/client’s medical condition, including significant signs or symptoms that would require the patient to seek immediate care.]

Our clinic is available to consult with you during the interim, while you locate a new provider of care, not to exceed [date same as first paragraph]. Our provider will authorize one refill of medications if required, but will not provide future refills beyond the discharge date.

If you require assistance in establishing care with another health care provider, please contact [your insurance company or the following professional societies].

Finally, once you have selected a new provider, you may contact our Health Records Department at (530) 752-6129 to obtain your records for your new provider. We wish you well.

Sincerely,

[Executive Director of Health and Wellness]