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Fill Out a Valid Aao Transfer Template

The Aao Transfer Form is a document used to facilitate the transfer of a patient’s orthodontic records from one provider to another. This form ensures that the new orthodontist receives all necessary information about the patient's treatment history and current status. Completing this form is essential for a smooth transition in care; click the button below to fill it out.

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Content Overview

Guide to Writing Aao Transfer

After completing the AAO Transfer form, it will be sent to the new orthodontist to ensure a smooth transition in the patient's treatment. This form collects essential information about the patient's current treatment status, medical history, and financial arrangements. Follow the steps below to fill out the form accurately.

Enter the date at the top of the form.
Fill in the name and contact information of the new provider.
Provide the current provider's name and contact information.
Complete the patient's personal information, including name, birth date, sex, and social security number.
List the responsible party's name and relationship to the patient.
Fill in the home address, city, state/province, and zip code.
Detail the analysis of the patient's condition, including significant history and TMD.
Document any patient or parent concerns regarding treatment.
Outline any special health or history concerns.
Describe the treatment plan, including a chronology of treatment rendered.
Summarize the treatment progress with a chronology of what has been done.
Specify details about appliances used, including type, manufacturer, and dates initiated.
Assess patient cooperation regarding oral hygiene, headgear, elastics, and appointments.
Estimate active treatment time, noting original and remaining time, as well as the percentage of treatment completed.
Provide recommendations for continued treatment and retention.
Add any additional comments that may be relevant.
Fill in financial details, including status (closed, open end, etc.), fees, and any outstanding amounts.
Indicate the records available for transfer and their status.
Sign and date the form as the orthodontist.
Request the patient or guardian to sign and date the authorization for record transfer.

Document Breakdown

Fact Name	Description
Purpose	The AAO Transfer Form is designed to facilitate the transfer of orthodontic patient records between providers, ensuring continuity of care.
Patient Information	Essential details about the patient, including name, date of birth, and contact information, must be included to identify the individual accurately.
Active Treatment Status	The form requires information on whether the patient is in active treatment, which helps the new provider understand the current stage of care.
Financial Considerations	It outlines the financial arrangements, including any unpaid balances and the potential for increased costs due to the transfer.
Record Transfer	Records such as initial and progress x-rays, photos, and treatment plans must be transferred to ensure the new provider has complete information.
Patient Cooperation	Details about the patient's cooperation with treatment, including oral hygiene and attendance at appointments, are documented to inform the new provider.
Governing Laws	In some states, such as California, the transfer of medical records is governed by the California Civil Code Section 56.10, which outlines patient privacy rights.

FAQ

What is the purpose of the AAO Transfer Form?

The AAO Transfer Form is designed to facilitate the transfer of a patient's orthodontic records from one provider to another. This form ensures that the new orthodontist has all necessary information about the patient's treatment history, current status, and future treatment plans. It helps maintain continuity of care and supports effective communication between the previous and new providers.

What information is required to complete the AAO Transfer Form?

To complete the AAO Transfer Form, you will need to provide several key pieces of information, including:

Patient's name and birth date
Contact information for both the current and new orthodontist
Details about the patient's treatment history and progress
Any special health or history concerns
Financial information related to the treatment

Completing this information accurately will help ensure a smooth transition to the new provider.

How does the transfer of records affect treatment costs?

It is important to note that transferring orthodontic treatment may lead to changes in treatment costs. Fees for orthodontic services can vary significantly between providers. Patients should expect that the total treatment cost may increase after the transfer. This is due to differences in pricing policies and the potential need for additional treatments to complete the ongoing care.

What happens to the patient's financial obligations during the transfer?

When a patient transfers to a new orthodontist, any outstanding balances or fees should be clearly communicated. The AAO Transfer Form includes sections to document the total charges before transfer, amounts paid, and any unpaid balances. Patients should discuss their financial obligations with both the current and new providers to ensure clarity regarding payment responsibilities.

Can records be sent directly to the new orthodontist?

Yes, the AAO Transfer Form allows for records to be sent directly to the new orthodontist. The current provider must complete the form and indicate whether records are enclosed or will be sent under separate cover. This helps ensure that the new orthodontist receives all necessary documentation to continue the patient's treatment without delay.

Who needs to sign the AAO Transfer Form?

The AAO Transfer Form must be signed by either the patient or a guardian if the patient is a minor. This signature authorizes the release of the patient's records to the new provider. It is essential for ensuring that the transfer is conducted legally and ethically, respecting the patient's privacy and rights.

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Aao Transfer Example

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 ______________________________