[Insert Company Letterhead]
Dear ______,
At ______Dialysis Center we have missed not seeing you. We believe that communication is an important part of a good relationship between our patients and the dialysis facility. Not coming to treatment in the past month has made it impossible for us to provide you with the care that you need. Your last treatment was on ______. Since that time we have made numerous phone calls to you requesting contact with you. We have tried calling you on ______. On ______, we placed a call to the ______Police Department requesting a welfare check. The officer informed us ______.
We are very concerned about you not coming to your scheduled treatments. As you are aware, your illness, end-stage renal disease, will only get worse if you are not getting consistent treatments. If you do not continue regular treatments, you may develop some of the following symptoms: ______, ______, ______, ______, ______. If you develop any of these symptoms, please contact 911 or go to the nearest hospital emergency room where you will be evaluated for dialysis.
Due to your extended absence from regular dialysis, we believe it is necessary that you be evaluated for your dialysis needs urgently, so we are requesting you call 911 or report to an Emergency Room. Following your hospital evaluation, you are welcome to return to this facility with your physician approval/orders.
After a prolonged absence (30 days or more) from regular dialysis treatments, it is customary to be placed on our 'inactive roster' and we will report to the ESRD Network accordingly. After being placed on the 'inactive roster' you are still welcome to return to this facility provided your physician approves readmission. However, it will be necessary for you to go through the readmission process. Following you return to 'active status' we will expect you to attend a patient care conference within the first week of readmission in order to discuss expectations and develop a plan of care that will meet your needs.
Your care team is available to discuss any questions or concerns that you have. You may reach ______at ______, Monday through Friday between the hours of ______. By not contacting us by ______, you are indicating that you no longer want us to serve as your dialysis provider and that you have decided to withdraw from dialysis.
While we wish to remain your provider, we recognize patients do have a choice. If you have chosen to seek care in an alternate facility, then please advise us at your earliest convenience so that we may transfer your records.
If you feel you have been treated wrongly or denied medical care without reason, you may file a complaint with the:
Texas Department of State Health Services
Facility Licensing and Compliance Division
1100 West 49th St.
Austin, TX 78756
888-973-0022
You may also file a complaint with:
ESRD Network 14 of Texas, Inc.
4040 McEwen Rd, Ste. 350
Dallas, TX 75244
877-886-4435
Sincerely,
Medical Director Clinical Manager/Coordinator
______
Social Worker Date
**ESRD Network 14 provides this template for guidance purposes. This template is not a substitution for the CMS Conditions for Coverage regarding patient discharges.