Patient Dismissal Letters - Sample

Sep 15, 2026

Patient dismissal letter templates used by dental practices to formally end the dentist-patient relationship due to noncompliance with the practice’s financial policy. The letters outline prior contact attempts, state the termination decision, and provide a limited thirty-day period for emergency treatment only. They explain how dental records will be forwarded after receiving a signed written authorization, including required recipient details and mailing timelines. Alternate wording supports outreach and inactive-record status if no response is received.

LanguageEnglish

CategoryLetters

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Sample Patient Dismissal Letter Templates

Termination of Dentist-Patient Relationship

Emergency Treatment Period

Dental Records Transfer Process

Follow-up and Inactive Record Status

Sample Patient Dismissal Letter Practice Letterhead Date Dear (Patient), We have contacted you on several occasions with monthly statements, telephone messages and a personal letter concerning your outstanding balance with our practice. We have determined that due to your noncompliance with our practices’ financial policy we must terminate our dentist-patient relationship. In order to allow you adequate time to find another dentist, we will be available for the next thirty days for emergency treatment only. If you need assistance in finding another dentist, you may contact the local dental society at: or utilize other resources (e.g. the internet) . We will forward a copy of your dental records to you or your new dentist upon receiving a signed written authorization request. Please clearly indicate whom you wish to receive a copy and where you wish us to send the records. Please allow five business days from receipt of your request for duplication and mailing. Signature, CC Patient File © ADA 2015. Reproduction of this material by ADA member dentists and their staff is permitted. Any other use, duplication or distribution by any other party requires the prior written approval of the American Dental Association. This material is educational only, does not constitute legal advice, and may not satisfy applicable state law. Changes in applicable laws or regulations may require revision. Contact a qualified lawyer or professional for legal or professional advice. Sample Patient Dismissal Letter Practice Letterhead Date Dear (insert patient’s first name): It’s been (insert time frame) since we’ve seen you and we’re concerned about your oral health. We’ve reached out several times to remind you that maintaining your oral health is important. We have not heard back from you. Please call us at (insert phone number) and speak with (insert name of team member) so she can schedule an appointment for you to come in for a thorough exam . Unfortunately, if we do not hear from you by (insert date, perhaps one month from the date of the letter), your records will be shifted to inactive status. We would like to have you back in in our practice and hope you’ll contact us soon. Please let us know if you’re being seen at another dental practice. We’d also be interested to know what prompted you to seek care somewhere else; perhaps your information will help us identify an opportunity to improve our service. All of us at (insert practice name) wish you the well and hope that you continue to schedule regular preventive dental visits. Signature, CC Patient File © ADA 2015. Reproduction of this material by ADA member dentists and their staff is permitted. Any other use, duplication or distribution by any other party requires the prior written approval of the American Dental Association. This material is educational only, does not constitute legal advice, and may not satisfy applicable state law. Changes in applicable laws or regulations may require revision. Contact a qualified lawyer or professional for legal or professional advice.

FAQs

What is the reason stated for terminating the dentist-patient relationship?

Termination is tied to the patient’s noncompliance with the practice’s financial policy and lack of response after multiple outreach attempts.

How long does the practice offer emergency treatment after dismissal?

The practice indicates it will be available for the next thirty days for emergency treatment only.

What is required to forward dental records to a new dentist?

A signed written authorization request is required, specifying who should receive the records and the mailing destination; duplication and mailing take about five business days from receipt.

Sep 15, 2026

Uploaded by Lucas Vance