VIA: CERTIFIED MAIL / RETURN RECEIPT REQUESTED

Dear ____________________:

This letter is to inform you that I am no longer able to continue as your physician.

As you are aware, you have a condition that requires further medical attention. I recommend 
that you contact a physician to provide those services to you without delay. During the
interim, but for no longer than 30 days from the date of this letter, I will provide you with
emergency medical care.

At your request I will provide either you, or the physician you select, a copy of your complete
medical record. Please sign and return to me the attached medical record authorization. If 
you have a problem selecting a physician, I suggest you contact the ____________County Medical
Society for a list of physicians practicing in your local area.

Sincerely,



_____________________________, M.D.



dated: ______________