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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 _________________________________________

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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

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)

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© American Association of Orthodontists 2014

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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© American Association of Orthodontists 2014

Document Information

Fact Name Description Governing Law
Purpose of the Form The AAO Transfer Form is designed to facilitate the transfer of patient records between orthodontic providers. None (General Practice)
Patient Information Required It requires detailed patient information, including personal details, treatment history, and financial status. HIPAA (Health Insurance Portability and Accountability Act)
Records Transfer Patients must authorize the release of their records to ensure continuity of care with the new provider. State-specific privacy laws
Financial Considerations The form notes that transferring may lead to changes in treatment fees and payment policies. Consumer Protection Laws

Aao Transfer - Usage Guidelines

Filling out the AAO Transfer form is an important step in ensuring a smooth transition of orthodontic care. Once completed, the form should be submitted to the current orthodontist to facilitate the transfer of records to the new provider. Follow these steps to accurately fill out the form.

  1. Date: Write the current date at the top of the form.
  2. To: Fill in the name of the new orthodontist or provider.
  3. From: Enter the name of the current orthodontist.
  4. Contact Information: Provide the phone number, fax number, and email address of the current orthodontist.
  5. Patient's Information: Fill in the patient's name, birth date, sex, and Social Security number. Include the patient's phone number.
  6. Responsible Party: Enter the name and relationship of the person responsible for the patient, along with their home address, city, state/province, and zip code.
  7. Analysis: Summarize the patient's significant history and any concerns related to temporomandibular disorder (TMD).
  8. Patient/Parent Concerns: Note any concerns regarding the treatment.
  9. Special Health or History Concerns: Include any relevant health issues or history.
  10. Treatment Plan: Describe the treatment plan and chronology of treatments rendered.
  11. Treatment Progress: Document the progress of the treatment and any significant milestones.
  12. Appliances: Specify the types of appliances used, including details about fixed, extraoral, removable, and clear tray appliances.
  13. Patient Cooperation: Assess the patient's cooperation regarding oral hygiene, appointments, and appliance care.
  14. Active Treatment Time Estimates: Provide original treatment time, remaining time, and percentage of treatment completed.
  15. Recommendations for Continued Treatment: Offer any recommendations for ongoing care.
  16. Recommendations for Retention: Include any suggestions for post-treatment retention.
  17. Additional Comments: Write any other relevant comments that may assist the new provider.
  18. Financial Information: Fill in details about the financial status, including fees, payment terms, and outstanding balances.
  19. Available Records for Transfer: Indicate which records are available for transfer and check the appropriate status of those records.
  20. Signature: The current orthodontist must sign and date the form.
  21. Request to Transfer Records: The patient or guardian must authorize the release of records by signing and dating the request section.

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Dos and Don'ts

When filling out the AAO Transfer form, it's essential to ensure that the process goes smoothly. Here are some important dos and don'ts to consider:

  • Do fill in all required fields completely. Missing information can delay the transfer process.
  • Do double-check the contact information for both the sending and receiving orthodontists. Accurate details help facilitate communication.
  • Do provide a clear treatment history and any significant concerns. This information is crucial for the new provider to understand the patient's needs.
  • Do sign and date the form. An unsigned form may be deemed invalid and could hinder the transfer.
  • Don't leave any sections blank unless specified. Each part of the form is designed to gather important information.
  • Don't forget to inform the patient or guardian about the potential changes in fees. Transparency is key to maintaining trust.

By following these guidelines, you can help ensure a smooth transition for the patient during their orthodontic treatment.

Common mistakes

  1. Incomplete Patient Information: Failing to fill out all sections of the patient information can lead to delays. Ensure that the patient's name, birth date, and contact information are fully provided.

  2. Missing Treatment History: Not including a detailed treatment history can hinder the new provider's understanding of the patient's needs. Include significant history and any treatments already rendered.

  3. Omitting Financial Details: Forgetting to document financial arrangements may create confusion. Clearly outline any outstanding balances, payment terms, and financial agreements.

  4. Neglecting to Sign the Form: A common mistake is not signing the form. Without a signature, the transfer request cannot be processed. Always ensure the form is signed by the patient or guardian.

  5. Not Checking Record Status: Failing to indicate whether records are enclosed or sent separately can lead to miscommunication. Clearly mark the status of all records being transferred.

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