The Aao Transfer Form is a document used to facilitate the transfer of orthodontic records when a patient changes providers during active treatment. It captures essential patient information, treatment history, and recommendations for continued care. Completing this form is crucial for ensuring a smooth transition in treatment; please fill it out by clicking the button below.
The Aao Transfer form serves as a vital document in the orthodontic care process, particularly when a patient needs to transition between providers during ongoing treatment. This form captures essential patient information, including personal details such as name, birth date, and contact information, ensuring that the new orthodontist has a comprehensive understanding of the patient's history. It also includes sections dedicated to treatment analysis, patient concerns, and any special health considerations that may impact care. The treatment plan and progress sections provide a chronological overview of the services rendered, while the appliances section details the types of orthodontic devices used and their respective specifications. Additionally, the form outlines the patient's cooperation with treatment protocols, such as oral hygiene practices and appointment attendance. Financial aspects are also addressed, with clear information on fees, payment structures, and any outstanding balances. Finally, the form facilitates the transfer of important records, ensuring that both the patient and the new orthodontist are well-informed and prepared for the continuation of treatment.
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 _________________________________________
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© American Association of Orthodontists 2014
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
Panoramic
CBCT
Intra-oral scan
files
Intraoral x-rays
Facial photos
Intraoral photos
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)
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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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Completing the AAO Transfer form is an essential step when transitioning orthodontic care from one provider to another. This form collects important patient information and treatment history, ensuring a smooth handover for ongoing treatment. Follow the steps below to fill out the form accurately.
The AAO Transfer Form is designed to facilitate the transfer of orthodontic records when a patient changes orthodontists. This form ensures that the new provider receives all relevant information about the patient's treatment history, current condition, and financial arrangements. By using this form, both the patient and the new orthodontist can ensure a smooth transition and continuity of care.
The form requires various details, including:
This comprehensive information helps the new orthodontist understand the patient's needs and treatment history.
To initiate the transfer, the patient or guardian must complete the AAO Transfer Form. This includes authorizing the current orthodontist to release the patient's records to the new provider. Once the form is signed, the current orthodontist will send the necessary records, which may include treatment plans, progress notes, and financial details, to the new orthodontist. This process helps ensure that the new provider has all the information needed to continue treatment effectively.
Yes, transferring orthodontic treatment may lead to additional costs. The patient has been informed that fees can vary significantly among orthodontic practices. When changing providers, it is reasonable to expect that the overall treatment costs might increase, and there may be changes in payment policies. It's essential to discuss these potential changes with both the current and new orthodontist to understand the financial implications fully.
If you have concerns about your treatment while transferring to a new orthodontist, it is important to communicate these issues clearly. You can include any specific concerns on the AAO Transfer Form under the "Patient/Parent Concerns" section. Additionally, discussing these concerns directly with both your current and new orthodontist can help ensure that your treatment continues smoothly and that your needs are addressed.
Incomplete Patient Information: Failing to provide all required personal details, such as the patient's name, birth date, or Social Security number, can delay the transfer process.
Missing Contact Information: Not including accurate phone numbers or email addresses for both the current and new providers can lead to communication issues.
Neglecting Medical History: Omitting significant health or treatment history can hinder the new orthodontist's ability to provide appropriate care.
Inaccurate Treatment Plan Details: Providing vague or incorrect information about the treatment plan can create confusion for the new provider.
Forgetting Appliance Information: Not specifying the type of appliances used or their current status may complicate the continuation of treatment.
Ignoring Financial Obligations: Failing to clearly outline any outstanding payments or balances can lead to disputes between the patient and the new provider.
Overlooking Patient Cooperation: Not addressing the patient's cooperation level or attitude toward treatment may result in misunderstandings about the patient's commitment.
Insufficient Record Transfer Status: Not indicating whether records are enclosed or sent separately can create delays in the transfer process.
Signature and Authorization Errors: Missing signatures or incorrect dates can invalidate the transfer request, causing further delays.
The AAO Transfer Form is a crucial document that helps ensure a seamless transition of orthodontic care when a patient changes providers. However, several other forms and documents often accompany this transfer to provide a comprehensive overview of the patient's treatment history and current status. Below are some commonly used documents that complement the AAO Transfer Form.
In summary, these accompanying documents play an important role in ensuring that the transfer of care is smooth and efficient. They provide essential information that aids the new orthodontist in understanding the patient's unique needs and continuing their treatment effectively.
The Aao Transfer form shares similarities with the Patient Referral Form. Both documents facilitate the transfer of essential patient information between healthcare providers. The Patient Referral Form typically includes details about the patient's medical history, current treatments, and any specific concerns that the new provider should be aware of. Just like the Aao Transfer form, it emphasizes the importance of continuity in care and ensures that the receiving provider has all necessary information to continue treatment effectively.
Another comparable document is the Medical History Form. This form collects comprehensive information about the patient's past medical conditions, medications, and allergies. Similar to the Aao Transfer form, it aims to provide a holistic view of the patient's health, which is crucial for any ongoing treatment. Both documents prioritize understanding the patient's background to inform future care decisions.
The Treatment Progress Report is also akin to the Aao Transfer form. It documents the patient's journey through treatment, highlighting milestones and any adjustments made along the way. Both forms serve as a record of treatment history, ensuring that the new provider can quickly grasp the patient's status and any ongoing needs, thus facilitating a smoother transition.
The Consent for Treatment form shares a connection with the Aao Transfer form as well. While the Aao form focuses on transferring records, the Consent form ensures that the patient or guardian understands and agrees to the treatment plan. Both documents are essential for maintaining clear communication and consent between the patient and healthcare providers, which is vital for ethical practice.
The Insurance Information Form is another document that bears similarities to the Aao Transfer form. This form collects details regarding the patient's insurance coverage, which is crucial for financial arrangements during treatment. Like the Aao Transfer form, it addresses the financial aspects of care, ensuring that both the patient and the new provider are aware of any potential changes in coverage or costs associated with the transfer.
The Treatment Plan Outline also resembles the Aao Transfer form in its purpose. It provides a detailed overview of the recommended treatment steps and expected outcomes. Both documents are designed to keep all parties informed about the treatment process, ensuring that the new provider can effectively continue the patient's care without missing critical information.
The Appointment History Log can be compared to the Aao Transfer form as well. This log tracks the patient's attendance and compliance with scheduled appointments. Both documents emphasize the importance of patient cooperation in the treatment process. By documenting attendance, the new provider can better understand the patient's commitment to treatment and any potential barriers they may face.
Lastly, the Financial Agreement Form is similar to the Aao Transfer form in that it outlines the financial obligations related to treatment. It details payment plans, outstanding balances, and any agreements made prior to the transfer. Both documents aim to clarify financial expectations and ensure that the new provider is aware of any existing arrangements, which is essential for a seamless transition in care.
When filling out the AAO Transfer form, careful attention to detail can make a significant difference. Here are ten important dos and don'ts to keep in mind:
By adhering to these guidelines, the transfer process can be smoother for both the patient and the new orthodontist.
This form is designed for any patient who needs to transfer their orthodontic records, regardless of their satisfaction level. Life changes, such as relocation, can necessitate a transfer.
While it may seem overwhelming, the form is straightforward. Most sections require basic information about the patient and their treatment history.
Patients can still request a transfer of records even if there are unpaid fees. However, financial obligations should be addressed with the current provider.
The form facilitates record transfer but does not ensure that the new provider will take on the patient. It’s best to confirm acceptance before initiating the transfer.
While patients need to provide specific information, they can seek assistance from their current orthodontist’s office to complete the form accurately.
Once the form is submitted, processing may take time. It’s important to allow for adequate time for the transfer to be completed.
Some offices may charge a fee for record duplication or transfer, but not all do. It’s advisable to check with both the current and new orthodontic offices.
Although primarily for orthodontic transfers, the principles of record transfer apply across various medical fields, making it relevant in broader contexts.
The purpose of the Aao Transfer form is to ensure that all relevant treatment history and records are sent to the new provider, preserving continuity of care.
Patients are free to return to their previous orthodontist if they wish, as the transfer does not limit future treatment options.
The AAO Transfer Form is essential for patients in active orthodontic treatment who need to change providers.
Accurate completion of all fields is crucial. This includes patient information, treatment history, and concerns.
Document the patient's current treatment plan and progress to ensure continuity of care.
Specify any special health or history concerns that may affect treatment.
Detail patient cooperation levels, including oral hygiene and attendance at appointments.
Be aware that transferring may result in changes to treatment fees and payment policies.
Include all relevant records, such as x-rays and progress notes, to provide a complete picture for the new provider.
Obtain the necessary signatures from both the current provider and the patient or guardian to authorize the transfer.