Patient Dismissal Letter from Medical Practice

Posted in Dismissal Letters

The relationship between a patient and a medical practitioner can sometimes become less than ideal for different reasons. Patients may fail to pay their bills, disregard medical advice, fail to show up for appointments or conduct themselves in ways that go against office policy. When events like these occur, medical personnel have the right to send patients a patient dismissal letter from the medical practice.

Format and Content

When medical office staff members write a dismissal letter from a medical practice, there must be certain information given. A proper patient dismissal letter from medical practice format should state the reason for dismissal, office policies, payment information and more. Contact information such as the office phone numbers, address, effective dismissal date and any other vital information should be included as well. It is also recommended that copies of medical polices allowing patient dismissal be sent with this letter.


This sample patient dismissal letter from a medical practice is written for a small town medical practice, Prichard’s Medical Practice, located in Williamsburg, Virginia. It is being sent to Lacy Wily, a patient who has been with this practice for four years but has recently failed to comply with treatment for her knee problems. Her doctor recommends that she have a knee replacement surgery. However, she is not in compliance and has become unresponsive to the office’s phone calls.

Dr. Amanda Prichard

Head Practitioner

Prichard’s Medical Practice

1873 NW 5th Street

Williamsburg, Virginia 71284

(734) 892-0378

September 5, 2013

Lacy Wily

1785 NE Bryan Road

Williamsburg, Virginia 71284

(734) 239-0153

Dear Lacy,

I sincerely regret to inform you that I can no longer provide you with medical care. Our records indicate that you have not responded to any of our calls to set up your knee treatment plan. Our records show that we have left five different messages on different days of the week at the number shown above. However, you have consistently failed to respond. As you are aware of your unhealthy condition and are in great need of knee replacement surgery, I suggest that you begin looking for a new doctor as soon as possible.

If these calls were made to the wrong phone number and we have made a mistake in our records, please contact our office staff as soon as possible so that we may correct this mistake. If however, you have simply neglected to respond to our phone calls, we regret to inform you that we will take the following actions if we are not contacted within five business days of this letter being mailed.

The availability of our services will be terminated.

I will be able to provide you with emergency medical care for up to 30 days of this notice being received. However, please note that this will be on a cash only plan. You must still begin to look for medical services elsewhere. If you have not contacted our office within the five business days provided to you, then we must assume that this letter was not written in error and our services will no longer be available; termination will be effective immediately.


Amanda Prichard

Dr. Amanda Prichard

Head Practitioner

Prichard Medical Practice

Please find a copy of our Medical Services Policy attached.

Create your own professional looking resume for free using our resume builder!