Healthcare Termination Notice

HEALTHCARE TERMINATION NOTICE

Notice Date:    Provider Name:

Provider Contact Information

Patient Information

Date of Birth:    Gender: Male Female Other Prefer not to say

Insurance Information

Termination Details

Effective Termination Date:

Non-payment of fees Coverage terminated by insurer Patient requested termination Failure to follow treatment plan

Fraud or material misrepresentation Provider closure or relocation Other:

Standard Notice Period (days):    Appeal Window (days from receipt):

Appeals and Continuity of Care

The patient has the right to request an appeal of this termination. Appeals must be submitted in writing within the Appeal Window indicated above. To file an appeal, contact:

Where required by law or professional standards, transitional care will be offered for an appropriate period to avoid interruption of medically necessary services. Transitional care arrangements, if any, are described below:

Records, Privacy, and Post-Termination Access

Patient retains the right to access medical records created prior to the Effective Termination Date. Release of records to a new provider will be made upon receipt of a written authorization signed by the patient or authorized representative. The patient's privacy will continue to be protected in accordance with applicable law prior to and after termination.

I acknowledge that I have received a copy of the provider's Notice of Privacy Practices and that I understand how to request access to my medical records and how to request transfer of records to another provider.
Acknowledgement:

Administrative Certification

The signer below certifies that the information contained in this notice is true and correct to the best of their knowledge, that required notice was provided consistent with applicable law and contractual obligations, and that the provider has complied with all applicable requirements prior to the effective date of termination. Final billing and refund procedures, if applicable, will be conducted in accordance with provider policy and applicable law.

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