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Download Aao Transfer Form in PDF

The Aao Transfer Form is a document used to transfer orthodontic records from one provider to another during a patient's active treatment. This form ensures that the new orthodontist has all the necessary information to continue care effectively. If you need to fill out the form, click the button below.

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The Aao Transfer Form plays a crucial role in ensuring a seamless transition for patients who need to change their orthodontic provider during active treatment. This form captures essential patient information, including personal details, treatment history, and any specific concerns that may impact ongoing care. It outlines the patient's current treatment plan, detailing the progress made and the appliances used, while also addressing patient cooperation and attitudes toward treatment. Additionally, the form highlights financial aspects, such as fees incurred and any outstanding balances, ensuring transparency between the transferring and receiving offices. Importantly, it allows for the transfer of necessary records, including diagnostic images and treatment notes, which are vital for the new provider to understand the patient's unique orthodontic needs. By providing a structured format for this information, the Aao Transfer Form facilitates effective communication among healthcare providers, ultimately enhancing the patient experience during a potentially stressful transition.

Preview - Aao Transfer Form

AAO TRANSFER FORM

PATIENT IN ACTIVE TREATMENT

Date _______________

To ____________________________________________________

From __________________________________________________

Phone ___________________ Fax __________________ Email: __________________________________________________

Patient's name _______________________________________ Birth date ____________________ Sex _________________

Social Security # __________________________ Phone ___________________

Responsible party __________________________________ Relationship: ____________________

Home address __________________________City _________________ State/Province ____________ Zip code __________

ANALYSIS (Including significant history & TMD) ________________________________________________________________

________________________________________________________________________________________________________

PATIENT/PARENT CONCERNS RE: TX _______________________________________________________________________

SPECIAL HEALTH OR HISTORY CONCERNS ___________________________________________________________________

TREATMENT PLAN (Including chronology of treatment rendered) _________________________________________________

________________________________________________________________________________________________________

TREATMENT PROGRESS (Including chronology of treatment rendered)____________________________________________

________________________________________________________________________________________________________

APPLIANCES

Fixed appliance:

Type_______________ Manufacturer _____________ Type of bracket: metal or non-metal Variations__________

Date bands and/or brackets placed: Max_______ Mand _______ Bonding Agent _______ Cementing Agent _________

Current archwire size and type: Max ______________ Mand _________________

Intraoral elastics: dates initiated, size and direction_____________________ Hours requested______________________

Extraoral appliance:

Type________________ and dates initiated______________________ Hours requested ____________________________

Removable appliance:

Type and dates initiated______________________________ Hours requested _________________________

Clear tray appliance:

Manufacturer _______________ Total trays ______ Trays delivered______ Change interval __________________________

Case/Patient number______________________

PATIENT COOPERATION

Oral hygiene __________________________________________ Headgear _________________________________________

Elastics ______________________________________________ Clear trays _______________________________________

Appointments _________________________________________ Broken appliances ________________________________

Patient's attitude toward treatment ________________________________________________________________________

Suggestions for patient motivation _________________________________________________________________________

ACTIVE TX TIME ESTIMATES Original _________________________ Remaining _____ % of active treatment completed

RECOMMENDATIONS FOR CONTINUED TREATMENT __________________________________________________________

______________________________________________________________________________________________________

RECOMMENDATIONS FOR RETENTION _____________________________________________________________________

ADDITIONAL COMMENTS _______________________________________________________________________________

_____________________________________________________________________________________________________

FINANCIAL

Closed ______________ Open End (Fixed) _______________Other ______________________

Fees: Active _______________ Extras ______________________________________________

Terms ________________________________________________________________________

Third party payment ____________________________________________________________

Total charges before transfer _________________________

Total amount paid before transfer _____________________

Unpaid amount still owed transferring office ____________

Balance of original quoted fee not yet charged ______________ or overpaid at transfer ______________

This patient/parent has been advised that orthodontic treatment fees vary widely throughout the country and the world and it is reasonable for them to expect that a transfer may increase treatment fees and may involve changes in payment policies. For most people who transfer during their orthodontic treatment, the total treatment cost is likely to increase.

AVAILABLE RECORDS FOR TRANSFER
Casts	Initial	Date ________	Progress Date ________ Articulator type________
Ceph	Initial Date ________		Progress Date ________
Tracings	Initial	Date ________	Progress Date ________
Panoramic	Initial Date ________		Progress Date ________
CBCT	Initial Date ________		Progress Date ________
Intra-oral scan	Initial	Date ________	Progress Date ________
files
Intraoral x-rays	Initial	Date ________	Progress Date ________
Facial photos	Initial Date ________		Progress Date ________
Intraoral photos	Initial Date ________		Progress Date ________

Check appropriate status of records:

Record duplicates sent upon request (may be an additional charge to patient) Yes No

Records enclosed Yes No Records sent under separate cover Yes No

Signature: __________________________________________________Date_______________________

(Orthodontist)

REQUEST TO TRANSFER RECORDS TO NEW PROVIDER

When a patient moves, or, for other reasons, there is a necessity to change orthodontists during the course of ongoing orthodontic treatment, it is highly advantageous for all involved parties that the transfer be as prompt and convenient as possible. Of paramount importance is the identification of an orthodontist who will accept the patient and successfully complete the treatment.

The American Association of Orthodontists represents over ninety percent of the orthodontic specialists in the U.S. and Canada. Your current doctor is a member and will assist you in finding a qualified orthodontist.

It is necessary that your records be transferred to assure that the receiving orthodontist is knowledgeable of your orthodontic condition(s), orthodontic treatment goals, the current treatment plan, and related financial arrangements. To facilitate the transfer of these records, it is necessary that you complete the following:

I authorize Dr. ____________________ to release all records of ____________________ (patient’s name) for the

purpose of continuation of treatment by Dr. ___________________(new provider’s name).

Signature: __________________________________________________________Date_______________________

(Patient or Guardian)

Print Name ________________________________________

Relationship to Patient ______________________________

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Document Specifics

Fact Name	Description
Purpose of the Form	The Aao Transfer Form is used to facilitate the transfer of orthodontic records when a patient changes providers during active treatment.
Patient Information	Essential details such as the patient's name, birth date, and contact information must be included to ensure accurate record transfer.
Legal Considerations	In states like California, the transfer of patient records is governed by the California Business and Professions Code, which mandates that patient consent is required for the release of records.
Financial Implications	The form advises patients that treatment fees may vary with a transfer, potentially increasing overall treatment costs and altering payment policies.

Aao Transfer: Usage Instruction

Completing the AAO Transfer form is a straightforward process that helps ensure your orthodontic treatment continues smoothly with a new provider. By following these steps, you can provide all the necessary information to facilitate the transfer of your records.

Date: Write the current date at the top of the form.
To: Fill in the name of the new orthodontist or provider.
From: Enter the name of your current orthodontist.
Contact Information: Provide the phone number, fax number, and email address of your current orthodontist.
Patient Information: Fill in the patient’s name, birth date, sex, and social security number. Include a phone number for the patient.
Responsible Party: Enter the name and relationship of the person responsible for the patient.
Home Address: Write the complete home address, including city, state/province, and zip code.
Analysis: Describe any significant history and concerns related to the patient's treatment.
Patient/Parent Concerns: Note any specific concerns regarding treatment.
Special Health or History Concerns: Mention any health issues that may affect treatment.
Treatment Plan: Outline the treatment plan, including a chronology of treatments rendered.
Treatment Progress: Document the progress made in treatment, including dates and milestones.
Appliances: Specify details about any fixed, extraoral, removable, or clear tray appliances used.
Patient Cooperation: Assess the patient's cooperation regarding oral hygiene and appointments.
Active Treatment Time Estimates: Provide estimates for original and remaining active treatment time.
Recommendations: Include any recommendations for continued treatment and retention.
Financial Information: Fill in the financial details, including fees and payment status.
Available Records for Transfer: Check the appropriate boxes regarding the status of records.
Signature: Have the orthodontist sign and date the form.
Request to Transfer Records: Complete the authorization section with the new provider's name and the patient's name.
Signature of Patient or Guardian: The patient or guardian must sign and date the authorization.
Print Name: Include the printed name and relationship to the patient.

Learn More on Aao Transfer

What is the purpose of the AAO Transfer Form?

The AAO Transfer Form is designed to facilitate the transfer of orthodontic records from one provider to another. When a patient needs to change orthodontists, this form ensures that all relevant information about their treatment is shared. This helps the new provider understand the patient's current condition, treatment history, and any special concerns.

What information do I need to provide on the form?

When filling out the AAO Transfer Form, you will need to provide several key details, including:

Patient's name and date of birth
Contact information for both the current and new orthodontist
A summary of the patient's treatment history and progress
Details about any appliances used
Financial information regarding treatment costs

Providing complete and accurate information will help ensure a smooth transition to the new orthodontist.

How does the transfer process work?

To initiate the transfer, the patient or guardian must complete the AAO Transfer Form and sign it. This signature authorizes the current orthodontist to release the patient's records to the new provider. Once the form is submitted, the current orthodontist will prepare the necessary records and send them to the new orthodontist. This process helps maintain continuity of care.

Will transferring my records affect the cost of treatment?

Yes, transferring orthodontic records can impact the overall cost of treatment. Fees for orthodontic services can vary widely between providers. Patients should be aware that the new orthodontist may have different pricing structures, which could result in an increase in treatment costs. It’s essential to discuss these potential changes with the new provider before finalizing the transfer.

What if I have special health concerns?

If you have special health concerns, it is crucial to communicate them on the AAO Transfer Form. The section dedicated to health concerns allows you to outline any significant medical history that may affect your orthodontic treatment. This information will help the new orthodontist tailor the treatment plan to meet your specific needs.

Can I request copies of my records?

Yes, you can request copies of your orthodontic records. The AAO Transfer Form includes a section where you can indicate if you would like duplicates of your records sent to you. Keep in mind that there may be an additional charge for these copies. It’s advisable to clarify this with your current orthodontist when making your request.

Common mistakes

Filling out the AAO Transfer Form can seem straightforward, but there are several common mistakes that people often make. Understanding these pitfalls can help ensure a smooth transfer process. One frequent error is leaving out critical contact information. The form requests phone numbers, fax numbers, and email addresses for both the sending and receiving orthodontists. Omitting any of this information can delay the transfer of records, creating unnecessary complications.

Another common mistake involves inaccuracies in patient details. It’s essential to double-check that the patient's name, birth date, and Social Security number are correct. Even a small typo can lead to significant issues, especially when it comes to verifying insurance or accessing medical records. Always verify this information before submitting the form.

People also tend to overlook the section on treatment progress. This part of the form is crucial for the new orthodontist to understand the patient's current status. Failing to provide a detailed account of the treatment timeline or progress can leave the new provider without the context needed to continue care effectively. Be thorough and clear in this section to avoid confusion.

Additionally, many individuals forget to sign the form. A signature is not just a formality; it is a legal requirement for the release of medical records. Without it, the transfer cannot be processed. Always ensure that the form is signed and dated appropriately before submission.

Another area where mistakes occur is in the financial section. Patients often neglect to clarify any outstanding balances or payment arrangements with their current orthodontist. This oversight can lead to misunderstandings regarding fees and obligations, which may complicate the transfer. It’s wise to communicate with the current provider about any financial matters before filling out this part of the form.

Lastly, some people fail to check the status of records being sent. The form includes options to indicate whether records are enclosed or will be sent separately. Not marking this correctly can create confusion about what documents are being transferred. Always ensure that the correct status is indicated to facilitate a smooth handoff of records.

Documents used along the form

The Aao Transfer form is a vital document in the process of transferring a patient’s orthodontic records from one provider to another. However, it is often accompanied by several other forms and documents that help ensure a smooth transition. Below is a list of these additional forms and documents, each serving a unique purpose in the transfer process.

Patient Consent Form: This document grants permission for the current orthodontist to release the patient’s records to the new provider. It ensures that patient privacy is respected and that the transfer is authorized.
Financial Agreement: This form outlines the financial arrangements between the patient and the current orthodontist. It details any outstanding balances, payment plans, and the financial implications of the transfer.
Medical History Form: This document provides a comprehensive overview of the patient’s medical background. It includes important health information that may affect orthodontic treatment and is crucial for the new provider to know.
Treatment Summary: A concise summary of the treatment that has been performed up to the point of transfer. This document includes details on procedures completed and any appliances used, giving the new orthodontist a clear picture of the patient’s progress.
Radiographs: These are essential imaging records, such as X-rays, that help the new orthodontist understand the patient’s dental structure. They are critical for planning future treatment.
Progress Notes: These notes document the patient’s treatment journey, including any challenges faced and adjustments made. They provide valuable insights into the patient's cooperation and treatment response.
Appliance Information: This document details any appliances currently in use, including fixed and removable devices. It helps the new provider understand what appliances need to be monitored or adjusted.
Appointment History: A record of past appointments, including dates and reasons for visits. This information can help the new orthodontist gauge the patient’s compliance and treatment timeline.
Transfer Summary Letter: A letter from the current orthodontist summarizing the patient's treatment status and any recommendations for future care. This letter can provide context for the new provider.

Each of these documents plays a crucial role in ensuring that the transfer of care is seamless and that the new orthodontist has all the necessary information to continue treatment effectively. By gathering these forms, both the patient and the new provider can work together to achieve the best possible outcomes.

Similar forms

The AAO Transfer Form shares similarities with the Patient Referral Form. Both documents facilitate the transfer of patient information between healthcare providers. The Patient Referral Form typically includes essential details such as the patient's medical history, current treatment plan, and specific concerns that need to be addressed by the new provider. This ensures that the receiving practitioner is fully informed about the patient's ongoing care and any special considerations that may impact treatment.

Another document comparable to the AAO Transfer Form is the Medical Records Release Form. This form allows patients to authorize the sharing of their medical records with new healthcare providers. Like the AAO Transfer Form, it requires the patient's consent and outlines the specific records being transferred. This document is crucial for maintaining continuity of care, as it ensures that the new provider has access to all relevant medical information, including treatment history and ongoing health concerns.

The Treatment Summary Document is also similar to the AAO Transfer Form. It provides a concise overview of a patient's treatment history, including diagnoses, procedures performed, and progress made. This summary is essential for new providers to quickly understand the patient's treatment journey and make informed decisions about future care. Both documents aim to keep the patient’s treatment consistent and effective by providing comprehensive information to the next provider.

The Continuity of Care Document (CCD) serves a similar purpose as the AAO Transfer Form. It is a standardized electronic document that contains a patient’s health information, including allergies, medications, and treatment history. The CCD ensures that all pertinent information is easily accessible to the new provider, thereby enhancing the quality of care. Both documents aim to streamline the transfer process and reduce the likelihood of gaps in treatment due to incomplete information.

The Discharge Summary is another document that parallels the AAO Transfer Form. It is typically created at the end of a patient’s treatment and summarizes their care, including outcomes and recommendations for future treatment. This summary provides the new provider with insights into the patient’s previous care and any follow-up actions that may be necessary. Both documents emphasize the importance of clear communication and thorough documentation in ensuring effective patient care.

Lastly, the Authorization for Release of Information Form is akin to the AAO Transfer Form. This form grants permission for healthcare providers to share a patient's personal health information with other parties. It is essential for ensuring that the new provider receives the necessary information to continue treatment. Both documents require the patient’s consent and are designed to protect patient privacy while facilitating the transfer of critical health information.

Dos and Don'ts

When filling out the AAO Transfer form, attention to detail is crucial. Here are five things to do and avoid:

Do provide accurate patient information, including full name and birth date.
Do include the current treatment plan and any significant history related to the patient's condition.
Do specify any special health concerns that may affect treatment.
Do indicate the status of financial arrangements clearly.
Do sign and date the form to authorize the transfer of records.

Don't leave any sections blank; incomplete information can delay the transfer process.
Don't forget to check the appropriate status of records being sent.
Don't omit any relevant details about the patient's cooperation or treatment progress.
Don't use abbreviations or unclear language that may confuse the receiving orthodontist.
Don't submit the form without verifying all information for accuracy.

Misconceptions

Misconception 1: The Aao Transfer form is only for patients who are unhappy with their current orthodontist.

This form can be used for various reasons, including relocation, changes in insurance, or simply needing a new provider.

Misconception 2: Completing the Aao Transfer form guarantees that the new orthodontist will accept the patient.

Acceptance depends on the new provider's availability and willingness to take on new patients.

Misconception 3: The transfer process is lengthy and complicated.

While it requires proper documentation, most orthodontists strive to make the process smooth and efficient.

Misconception 4: Patients must pay all fees upfront before transferring records.

Fees may vary by provider, and some offices allow for payment arrangements during the transfer process.

Misconception 5: Patients lose all progress made when they transfer to a new orthodontist.

The new provider will review the patient's history and treatment plan, allowing for continuity in care.

Misconception 6: The Aao Transfer form is only for orthodontic treatment.

This form can also be relevant for patients undergoing related dental treatments that require continuity of care.

Misconception 7: Transferring records is always a hassle.

Most orthodontists are familiar with the transfer process and will assist in ensuring records are sent promptly.

Key takeaways

When filling out the AAO Transfer form, it’s essential to provide accurate and complete information. Here are key takeaways to consider:

Patient Information: Ensure all personal details of the patient, including name, birth date, and contact information, are filled in correctly.
Responsible Party: Clearly identify the responsible party and their relationship to the patient.
Medical History: Include any significant medical history or concerns that may affect treatment.
Treatment Plan: Document the current treatment plan, including any treatment that has already been rendered.
Appliance Details: Specify the types of appliances used, including fixed and removable types, along with their specifications.
Patient Cooperation: Assess and note the patient’s cooperation with treatment, including oral hygiene and attendance at appointments.
Financial Information: Provide a clear breakdown of fees, including any outstanding balances and payment terms.
Transfer Records: Indicate which records are being transferred and ensure that the status of these records is marked correctly.
Signature Requirement: Both the current orthodontist and the patient or guardian must sign the form to authorize the transfer.
Consult New Provider: Make sure to identify and consult the new orthodontist who will continue the treatment.

Completing the form accurately can help ensure a smooth transition for the patient’s ongoing orthodontic care.