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Blank Aao Transfer PDF Form

The Aao Transfer Form is a document designed for patients undergoing active orthodontic treatment who need to transfer their care to a new provider. This form helps ensure that the new orthodontist receives all necessary information about the patient's treatment history, current status, and financial arrangements. To begin the transfer process, fill out the form by clicking the button below.

Article Guide

The Aao Transfer form plays a crucial role in the continuity of orthodontic care when a patient needs to change providers during active treatment. This form facilitates the transfer of essential patient information, ensuring that the new orthodontist has all necessary details to provide seamless care. Key components of the form include the patient's personal information, treatment history, and any specific concerns that may affect ongoing treatment. Additionally, it outlines the treatment plan, progress made, and the types of appliances used. Financial details, including fees and payment arrangements, are also addressed, highlighting the potential for changes in costs when transferring care. By capturing both clinical and administrative data, the Aao Transfer form serves as a comprehensive tool to support effective communication between healthcare providers, ultimately prioritizing the patient's needs and treatment outcomes.

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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 ______________________________

➤ PDF File

Form Specifications

Fact Name	Description	Governing Law
Purpose of the Form	The Aao Transfer Form facilitates the transfer of patient records between orthodontic providers, ensuring continuity of care.	State-specific regulations may apply.
Patient Information	The form requires detailed patient information, including name, birth date, and contact details, to accurately identify the patient.	HIPAA Privacy Rule governs patient information handling.
Treatment History	It includes sections for documenting the patient's treatment history, concerns, and progress, which are crucial for the new provider.	State dental practice acts may regulate treatment documentation.
Financial Considerations	The form addresses financial arrangements, informing patients about potential changes in fees when transferring care.	Consumer protection laws may influence fee disclosures.

Aao Transfer: Usage Guidelines

Filling out the AAO Transfer form is an important step in ensuring a smooth transition of care when changing orthodontic providers. Accurate completion of the form will help the new provider understand the patient's treatment history and current status. Follow these steps carefully to ensure all necessary information is provided.

Enter the date at the top of the form.
Fill in the recipient's name and contact information in the "To" section.
Provide your current orthodontist's name and contact information in the "From" section.
Include the patient's name, birth date, sex, and Social Security number.
List the responsible party's name, their relationship to the patient, and the home address, including city, state/province, and zip code.
In the "ANALYSIS" section, summarize the significant history and any TMD (temporomandibular disorders) concerns.
Document any patient or parent concerns regarding treatment in the designated area.
Outline the treatment plan, including a chronology of treatment rendered.
Describe the treatment progress in the appropriate section.
Detail the appliances used, including types and dates, as well as any other relevant information.
Note the patient’s cooperation regarding oral hygiene, appointments, and other aspects of treatment.
Estimate the active treatment time, indicating the original and remaining time.
Provide recommendations for continued treatment and retention.
Add any additional comments that may be relevant to the new provider.
Fill out the financial section, detailing the status of payments and any outstanding balances.
Indicate the availability of records for transfer and check the appropriate status of records.
Sign and date the form at the bottom, ensuring the orthodontist's signature is included.
Complete the request to transfer records section, including the patient's and guardian's signatures and relationships.

Your Questions, Answered

What is the purpose of the AAO Transfer Form?

The AAO Transfer Form is designed to facilitate the transfer of orthodontic records when a patient changes orthodontists. It ensures that the new provider has all necessary information regarding the patient's treatment history, current status, and financial arrangements. This helps maintain continuity of care and supports the new orthodontist in providing effective treatment.

What information is required on the AAO Transfer Form?

The form requires detailed patient information, including the patient's name, birth date, contact details, and responsible party information. Additionally, it asks for treatment history, patient concerns, treatment plans, progress, and appliance details. Financial information and records status are also included to ensure a comprehensive transfer.

How does a patient authorize the transfer of their records?

A patient or their guardian must sign the authorization section of the AAO Transfer Form. This section includes the names of both the current and new orthodontists and confirms the patient's consent to release their records for continued treatment.

Can a patient expect changes in treatment fees after transferring?

Yes, it is common for treatment fees to vary between orthodontists. The form advises patients that transferring may increase treatment costs and involve changes in payment policies. Patients should discuss these potential changes with their new provider.

What types of records can be transferred?

The AAO Transfer Form allows for the transfer of various records, including casts, cephalometric tracings, panoramic images, CBCT scans, intraoral scans, and photographs. The form indicates whether these records are included or if they will be sent separately.

What should a patient do if they have concerns about their treatment?

Patients are encouraged to express any concerns regarding their treatment on the form. This section allows them to detail their specific worries or issues, which can help the new orthodontist address these matters effectively.

How can patients ensure a smooth transfer process?

To ensure a smooth transfer, patients should complete the AAO Transfer Form accurately and provide all requested information. They should also communicate with both their current and new orthodontists to confirm that the transfer is being handled promptly.

What happens if records are not transferred promptly?

If records are not transferred in a timely manner, it may delay the new orthodontist's ability to continue treatment. This can impact the patient's care and prolong the overall treatment process. It is important for patients to follow up with both offices to ensure the transfer is completed.

Who can assist patients in finding a new orthodontist?

The current orthodontist can assist patients in finding a new provider. The American Association of Orthodontists, which represents a majority of orthodontic specialists in the U.S. and Canada, can also help locate qualified orthodontists for ongoing treatment.

Common mistakes

Incomplete Patient Information: Failing to provide all necessary details about the patient, such as their full name, date of birth, or social security number, can lead to delays in processing the transfer.
Incorrect Contact Information: Providing an incorrect phone number or email address for the current orthodontist or the new provider can hinder communication.
Missing Signatures: Not signing the form or having the wrong person sign it can invalidate the transfer request.
Omitting Treatment History: Failing to include a comprehensive treatment history can leave the new orthodontist without essential information needed for continuing care.
Neglecting Financial Details: Not accurately reporting any outstanding balances or financial arrangements can create confusion regarding payment responsibilities.
Ignoring Health Concerns: Overlooking significant health or history concerns can impact the new provider's ability to deliver safe and effective treatment.
Inaccurate Appliance Information: Providing incorrect details about appliances, such as type or manufacturer, may lead to complications in treatment continuity.
Failure to Document Cooperation: Not detailing the patient’s cooperation level regarding treatment can mislead the new provider about the patient’s commitment to their care.
Not Checking Record Status: Failing to indicate whether records are enclosed or need to be sent separately can lead to incomplete transfers.
Ignoring Additional Comments: Leaving the additional comments section blank can miss an opportunity to convey important information that might assist the new provider.

Documents used along the form

When transferring orthodontic care, several forms and documents accompany the AAO Transfer Form to ensure a smooth transition. Each document serves a specific purpose, providing essential information to the new provider about the patient's treatment history and needs. Below is a list of commonly used forms that help facilitate this process.

Patient Consent Form: This document grants permission for the current orthodontist to share the patient’s records with the new provider, ensuring that all necessary information is legally transferred.
Medical History Form: A comprehensive record detailing the patient's medical background, allergies, and any significant health issues that may impact orthodontic treatment.
Financial Agreement: This outlines the payment terms and conditions related to the treatment costs, including any outstanding balances and payment plans.
Treatment Progress Notes: A summary of the patient's treatment journey thus far, including any procedures completed and the patient's response to treatment.
Diagnostic Records: These include X-rays, photographs, and other imaging that provide a visual representation of the patient’s dental structure and alignment.
Appliance Information Sheet: This document details any appliances currently in use, including their types, adjustments made, and instructions for care.
Appointment History: A log of past appointments that highlights attendance, missed visits, and any rescheduling, providing insight into the patient’s compliance.
Referral Letter: A letter from the current orthodontist explaining the reasons for the transfer, along with a recommendation for the new provider.
Retention Plan: This outlines the strategies for maintaining the results achieved during treatment, including any retainers that may be necessary post-transfer.
Communication Preferences: A document indicating how the patient prefers to receive updates and information regarding their treatment, ensuring clear lines of communication.

Each of these documents plays a crucial role in ensuring that the new orthodontist has all the necessary information to continue treatment effectively. By preparing these forms, both the patient and the orthodontists can work together to make the transition as seamless as possible.

Similar forms

Patient Transfer Form: This document serves a similar purpose to the AAO Transfer form by facilitating the transfer of patient information from one healthcare provider to another. It typically includes personal details, treatment history, and any relevant medical concerns, ensuring continuity of care.
Medical Records Release Form: Like the AAO Transfer form, this document allows patients to authorize the release of their medical records. It is essential for ensuring that new providers have access to comprehensive medical histories, treatment plans, and any ongoing health issues that may impact care.
Continuity of Care Form: This form is similar in that it outlines the patient’s treatment history and current health status. It aims to provide the new provider with a clear understanding of the patient's ongoing needs, thus promoting effective treatment continuity.
Referral Form: A referral form often accompanies the transfer of care, detailing the reasons for the referral and any specific treatment recommendations. This document parallels the AAO Transfer form by ensuring that the receiving provider is fully informed about the patient's condition and treatment history.
Authorization for Release of Information: This document is crucial for allowing healthcare providers to share patient information legally. Similar to the AAO Transfer form, it ensures that all necessary patient data is transferred to the new provider, facilitating a seamless transition in care.

Dos and Don'ts

When filling out the AAO Transfer Form, attention to detail is crucial. Here’s a guide to help you navigate the process smoothly. Below are six important do's and don'ts:

Do ensure all patient information is accurate and complete. This includes names, dates, and contact details.
Do provide a thorough analysis of the patient's treatment history and any concerns. This helps the new provider understand the patient's needs.
Do list all appliances and their specifics, including types, dates, and any current issues. This information is vital for continuity of care.
Do communicate any special health or history concerns clearly. This ensures that the new orthodontist is aware of any potential complications.
Don't omit any financial details. Be transparent about fees, payments made, and any outstanding balances to avoid confusion later.
Don't rush through the form. Taking your time to fill it out accurately will prevent delays in treatment transfer.

By following these guidelines, the transfer process can be more efficient, ensuring that the patient's treatment continues seamlessly.

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 or changes in insurance, not just dissatisfaction.

Misconception 2: Completing the form guarantees immediate transfer of records.

While the form initiates the process, the actual transfer depends on the current provider's response and timing.

Misconception 3: The Aao Transfer form is complicated and difficult to understand.

The form is designed to be straightforward, requiring basic patient information and treatment details.

Misconception 4: Patients must pay additional fees to transfer their records.

While some providers may charge for record duplication, many do not impose extra fees for the transfer itself.

Misconception 5: All orthodontists will accept a patient transferring their care.

Not every orthodontist has the capacity or willingness to take on new patients, especially those in active treatment.

Misconception 6: The Aao Transfer form is not necessary if the patient is transferring to a new orthodontist.

The form is essential to ensure that the new provider has all necessary information to continue treatment effectively.

Misconception 7: The patient’s treatment plan will remain unchanged after the transfer.

Different orthodontists may have varying approaches, which can lead to adjustments in the treatment plan.

Misconception 8: The form does not include any financial information.

Financial details are a crucial part of the form, as they inform the new provider of any outstanding balances or payment arrangements.

Misconception 9: The Aao Transfer form can only be filled out by the patient.

Guardians or responsible parties can also complete the form on behalf of minors or patients unable to do so.

Misconception 10: Transferring records will delay the continuation of treatment.

Prompt completion of the Aao Transfer form can actually expedite the process, ensuring a smoother transition.

Key takeaways

When filling out and using the AAO Transfer Form, keep these key takeaways in mind:

Accurate Information: Ensure all fields are filled out correctly, including patient details, contact information, and treatment history.
Patient Consent: Obtain the patient's or guardian's signature to authorize the release of records to the new provider.
Complete Treatment History: Provide a thorough analysis of the patient's treatment progress, including any appliances used and their status.
Financial Clarity: Clearly outline any outstanding balances or fees to avoid confusion during the transfer.
Record Transfer: Indicate which records are being sent and ensure they are included or noted as sent under separate cover.
Timeliness: Aim to complete the transfer promptly to minimize disruption in the patient's treatment.
Communication: Maintain open lines of communication between the current and new orthodontists to ensure a smooth transition.