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No Further Service (1.2.6)

No Further Service (1.2.6) - Policies, Clinical, UW Health Clinical, Administrative, Legally Driven Care


Policy Title: No Further Service
Policy Number: 1.2.6
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: August 31, 2015


The purpose of the No Further Service (NFS) policy is to guide internal decision making on w hen it is
appropriate to terminate a patient relationship at UW Health and the corresponding process for doing so.
How ever, this policy is not intended to create any rights or expectations of continuing care and UW Health
expressly reserves the right to terminate a patient relationship for any reason permitted by law .

Scope of Policy: This policy covers termination of all provider-patient relationship(s) by one or more UW
Health provider(s), other than the situations listed below . When one or more UW Health provider(s)
terminate a relationship w ith a patient, it is referred to as a decision to provide “No Further Service.”

This policy does not apply to the follow ing situations:
Termination of the provider-patient relationship based on patient’s decision to seek care elsew here
or because the purpose for w hich the care w as sought has resolved (i.e., patient’s treatment is
complete and no follow -up care is medically necessary).
Patients w ho initiate termination of care. If a patient terminates the prov ider-patient relationship, it
is recommended that the provider document the patient comments and/or send a letter to the
patient confirming the termination of the relationship. Consult w ith Patient Resources as needed
for a template letter/process.
Patients w ho have not established a relationship w ith a provider. If a situation arises in w hich a
provider believes a new patient should not be allow ed to establish care, Patient Resources can be
contacted for consultation.
Emergency treatment; hospitals providing emergency services (including University Hospital (600
Highland Avenue), American Family Children’s Hospital and UW Health at The American Center)
are required by the Emergency Medical Treatment and Active Labor Act (EMTALA) to screen and
stabilize patients w ho present w ith an emergency medical condition, and may be required to
provide certain other treatment depending on the circumstances.


1. NFS: refers to a situation w here “No Further Service” w ill be provided to an established patient by a
specif ic provider(s), service/department/clinic or all of UW Health to a patient w ho is currently receiving
or previously received care.
2. Provider-patient relationship: refers to a relationship betw een a provider (individual or institutional)
and a patient. This relationship is generally established in one of tw o w ays:
a. The provider, in response to an express or implied request to treat the patient, agrees to care for
the patient; or
b. The provider engages in actions to provide care for a patient, such as by examining, diagnosing,
treating or prescribing medication for a patient.

If specif ic questions arise about the establishment of the relationship (e.g., a patient that is to receive
NFS is mistakenly scheduled for an appointment) legal advice should be obtained by calling the
appropriate Risk Management or Legal Department.
3. UW Health: includes University of Wisconsin Hospital and Clinics (UWHC), University of Wisconsin
Medical Foundation (UWMF), the University of Wisconsin School of Medicine and Public Health
(SMPH), and health care providers associated w ith any of those organizations.


Policy Title: No Further Service
Policy Number: 1.2.6

NFS requests w ill be managed centrally by Patient Resources and w ill generally involve one or more UW
Health Senior Physician Leaders.

It is the intent that UW Health providers w ill make good faith efforts to resolve differences/disagreements
w ith patients in order to meet their medical needs and promote continuity of care. How ever, UW Health
recognizes that there w ill be situations w here the relationship may become impaired and non-productive.
Prior to terminating a patient relationship, effort should be made to understand the breakdow n in the
relationship and resolve it. Generally, patients (or their legal representatives) should be informed of
concerns and allow ed a reasonable opportunity to resolve the concerns before a NFS determination is
made. Special considerations w ill be made in the cases of minors or other individuals w ho lack
decisionmaking capacity. Effort should be made to engage appropriate family members/supports, child,
adult or elder protective services as needed, etc. prior to requesting NFS.

NFS decisions w ill not be based on race, color, national origin, ancestry, disability, sex, gender identity or
expression, marital status, military or protected veteran status, sexual orientation, religion, age, creed, or
any other characteristic protected by local, state, or federal ordinance, law or regulation.

1. Preliminary Interventions.
a. When behavior or issues occur that raise concerns regarding the ability to deliver care to a
patient, Patient Resources should generally be contacted to assist in developing an
appropriate plan.
b. Preliminary interventions, such as assessing for and addressing barriers (e.g., lack of
insurance or transportation), setting expectations verbally and/or in w riting, or behavioral or
security-related plans should generally be attempted before initiating NFS to a patient w ho has
an ongoing relationship w ith a UW Health provider.
c. Before a NFS request is initiated, a patient should generally be provided w ith w ritten notice
summarizing the concerns and an opportunity to correct the concerns. A copy of the w ritten
notice should generally be included in the patient’s medical record.

2. Initiating NFS Requests. When a UW Health provider, clinic manager or other person w ould like to
initiate NFS to a patient, contact Patient Resources w ho w ill evaluate pertinent information to determine
w hether to propose preliminary interventions or to request NFS termination.
a. Behaviors or issues that may trigger a NFS determination include, but are not limited to, repetitive
no show s (see UW Health Ambulatory Patient No Show , Late Cancel and Late Arrival Policy),
irreconcilable differences betw een the individual and one or more providers; disruptive, threatening,
abusive or violent behavior; or harassment. This list is not intended to be exclusive and other
situations may also w arrant an NFS decision.
b. Key factors that should be considered w hen making a NFS determination include:
Response to preliminary interventions, such as w arnings or communications w ith the
patient regarding the behavior or other issues leading up to the NFS request;
Documentation in UW Health records of behaviors or concerns supporting a NFS
Any legal concerns, including federal and state law s prohibiting discrimination and
law s against refusing assessment, care, treatment, or transfer of patients;
Personal safety of UW Health personnel, visitors, patients and others;
Impact of the patient’s behavior on other patients;
Contractual or other legal obligations to provide care under HMO contracts,
conditions of participation in governmental programs, or other factors;

Policy Title: No Further Service
Policy Number: 1.2.6

A health condition that may not otherw ise be able to be safely managed or
transitioned to another setting.

3. Approval of NFS. Approval of a NFS request w ill be requested by Patient Resources as follow s:
a. For NFS from an individual ambulatory provider, service, clinic, or UW Health system-w ide
(excluding UWHC Emergency Department), the Chief Medical Officer (CMO), or designee,
approves. Patient Resources signs and sends the letter through HealthLink.

4. Notif ication to Patient. The patient should be notif ied of any NFS decision as follow s:
a. The notice letter should generally specify that the effective date of NFS is 30 days from the date of
the letter to allow the patient time to f ind another provider. In rare cases, it may be appropriate to
provide less than or greater than 30 days ’ notice of NFS; in these cases, the reasons should be
specif ically documented and discussed w ith the appropriate UW Health Risk Management or Legal
Department and, if a faculty physician is involved, UW-Madison Office of Legal Affairs. During the
notice period, only necessary prescription refills and/or urgent care w ill be provided. Rendering
non-urgent care can be construed as reestablishing the care relationship. If a provider re-
establishes the relationship, s/he must notify Patient Resources.
b. An "Authorization for Release of Medical Information" w ill be enclosed w ith the NFS notice letter to
facilitate transfer of medical records. If the NFS decision relates to substance abuse issues,
information regarding alcohol or drug treatment resources may be provided w ith in the letter.

5. UW Health Documentation. To notify UW Health staff of the NFS determination, Patient Resources
w ill:
a. Document in HealthLink as follow s: – FYI, change the PCP field to NO PCP Patient Resources
effective 33 days in the future (or in cases w here greater/few er than 30 calendar days’ notice is
given, the number of notice days plus 3 days), dismiss from scheduling, and document in patient
messages. If a patient is terminated from Urgent Care, a permanent comment w ill be documented
(patients w ill not be “blocked from scheduling” at the urgent care to allow for provision of care in an
emergent situation for terminated patients).
b. NFS notice letter is w ritten in the patient's medical record under CHART REVIEW - LETTERS tab
or in scanned documents.
c. Forw ard the NFS notice letter via inbasket as applicable to PBS Manager, Clinic Manager, the
appropriate provider(s), Medical Administration, and the ED Director and Urgent Care
Manager/Lead Physician as needed for system-w ide terminations. Once the NFS letter has been
signed, sent and forw arded to appropriate staff, the Manager should communicate NFS status to all
appropriate clinic staff.

6. Responding to Patient Requests After NFS Letter Sent.
a. Patient Calls. If the patient calls w ithin the 30-day notice period to make an appointment, the call
should be directed to the triage nurse to assess the acuity of the situation. If the patient’s needs are
urgent or emergent, the patient should be directed to the most appropriate level of care. If staff
refer the patient to another clinic for care, (e.g. Urgent Care), staff should notify that clinic. If not
emergent or urgent the patient should be transferred to Patient Resources and clinic staff should
notify their supervisor.
b. Patient Walk-Ins. If the patient arrives for a w alk-in appointment, the clinical support staff w ill
assess the acuity of the situation. If it is not-urgent, the patient can be redirected to Patient
Resources and the supervisor should be notif ied. If deemed urgent or emergent, the patient should
be evaluated for treatment or transfer, as appropriate. Contact Patient Resources to unblock
scheduling as needed.

Policy Title: No Further Service
Policy Number: 1.2.6

c. Patient Did Not Receive Letter. If the patient indicates they never received the NFS letter, staff
should transfer the patient to Patient Resources. If the certif ied NFS letter w as returned as
undeliverable, Patient Resources staff w ill read the NFS letter to the patient, update their mailing
address, resend the letters, and recalculate the 30-day urgent care period.
d. Pa tient Disputes NFS Decision. If a patient calls disputing the NFS, transfer the patient to Patient
Resources to investigate and consult w ith the care team and medical leadership regarding
decisions for future care.


Author(s): UW Health Director of Patient Resources
Senior Management Sponsor: UW Health Chief Ambulatory Medical Officer & UWHC Sr. VP Medical Affairs
Review ers: UW Health Chief Ambulatory Medical Officer, UWMF Medical Director Ambulatory Clinic
Operations, UWHC Sr. VP Medical Affairs, UWHC Director Patient Relations & Patient Family Partnerships,
UWMF VP Legal & Compliance, UWHC Sr. VP & General Counsel, UW-Madison Office of Legal Affairs Sr.
University Legal Counsel
Approval committees: UW Health Clinical Policy Committee, Medical Board
UW Health Clinical Policy Committee Approval: February 16, 2015

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.


Peter New comer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

Version: Original
Next Revision Due: August 31, 2018
Formerly Know n as: MF policy, No Further Service