Healthcare Debond Letter

HEALTHCARE DEBOND LETTER

To: Provider/Facility Name:   Account/Reference No.:

Patient Information

Insurance Information

Current Treatment / Bonding Details

Current treating clinician or department:   Bond start date:

Reason for Debond

Please indicate reason(s) for debonding (check all that apply):

Authorization for Transfer of Care and Records

I request that the Provider release my medical records and transfer continuity of care to the receiving provider named below, and that any bonding or contractual restrictions that prevent transfer of care be removed to the extent permitted by law and the parties' agreement.

Medical / Clinical Summary

Financial and Liability Acknowledgement

I acknowledge that debonding (termination of the bonding arrangement or provider association) does not automatically relieve me of financial obligations for services already rendered. I remain responsible for charges incurred prior to the Effective Date of debonding unless otherwise expressly agreed in writing by the Provider.

Proposed Effective Date of Debonding:

Financial arrangements proposed for outstanding balance (if applicable):

HIPAA and Privacy Acknowledgement

By signing below I authorize the disclosure of my protected health information to the receiving provider listed above to permit continuity of care. I understand that such disclosure will include clinical summaries, medication lists, and treatment history relevant to ongoing care. I acknowledge that I have the right to revoke this authorization in writing prior to its expiration, except to the extent that action has already been taken in reliance on it.

Certification and Signature

I certify under penalty of perjury that the information provided in this Healthcare Debond Letter is true, complete, and accurate to the best of my knowledge. I understand that submission of this letter is a formal request for release from the existing bonding arrangement and that Provider may require additional documentation or may provide a separate written agreement to confirm debonding terms. I further acknowledge that any changes to financial responsibility or release of obligations must be made in writing by an authorized representative of the Provider.

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