[Your letterhead, if desired; if not, your return address]

[Date of letter-month, day, and year]

[Recipient's first and last names]
[Company name]
[Street or P.O. box address]
[City, State ZIP code]

Dear [recipient's name]:

We are writing to notify you that effective immediately, our medical office will be terminating our professional relationship with you as our patient. We regret that we must make this decision, but this is necessary as a result of your repeated noncompliance with our medical instructions over recent weeks.

Our billing office will send to you a final bill for services provided by our office. Please notify us if you need to obtain a copy of your medical records from our office, and we will provide instructions on doing that. Also contact us if you have any questions about this termination. Thank you for your attention to this important matter.

Sincerely,

[Signature]

[Sender's first and last names]