Cover Letter Template Physician Disenrollment in Medi-Cal by seeme22

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									Physician Medi-Cal Participation Termination Cover Letter Template
Please Print on Physician’s Letterhead

Sandra Shewry, MPH, MSW
Director, Department of Health Care Services
Provider Enrollment Division
MS 4704
P.O. Box 997413
Sacramento, CA 95899-7413

RE: NOTICE OF TERMINATION OF MEDI-CAL PROVIDER AGREEMENT

Dear Ms. Shewry:

As a current provider in the Medi-Cal program of the Department of Health Care
Services (DHCS), I am writing to inform you that I am no longer able to subsidize the
care of low-income and uninsured Californians by sustaining a 10% provider
reimbursement rate cut, passed by the California legislature, effective July 1, 2008. I
simply cannot bear this burden and maintain a viable medical practice, which is why I am
asking that my participation in the Medi-Cal program be terminated at this time.

Please find below the information necessary to terminate my Medi-Cal provider
agreement.

         Physician’s Legal Name and/or DBA Name:
         Group Name (if applicable):
         Medi-Cal Provider Number(s):
         National Provider Identifier Type 1:
         National Provider Identifier Type 2 (if you have one):
         Business Address:
         Effective Date of Termination:

With sincerest regrets,

<physician’s signature>

Dr. XYZ

Cc:       San Diego County Medical Society (SDCMS)
          5575 Ruffin Road, Suite 250
          San Diego, CA 92123

								
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