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Blank Aao Transfer Form

The Aao Transfer Form is a document used to facilitate the transfer of orthodontic records when a patient changes providers during active treatment. This form ensures that the new orthodontist receives all necessary information regarding the patient's treatment history, current status, and any financial obligations. Completing this form helps streamline the transition, allowing for continuity in care and minimizing disruptions in the patient's treatment plan.

Outline

When a patient finds themselves in the midst of orthodontic treatment and needs to transfer to a new provider, the Aao Transfer Form plays a crucial role in ensuring a smooth transition. This form captures essential details about the patient, including their personal information, treatment history, and specific concerns that may affect ongoing care. It also outlines the treatment progress and any appliances currently in use, which helps the new orthodontist understand the patient's unique situation. Furthermore, it addresses financial considerations, noting any outstanding balances or changes in fees that may occur due to the transfer. By documenting all relevant records, such as x-rays and treatment plans, the form facilitates effective communication between the current and new orthodontic offices, ultimately supporting the patient’s continued care. Completing the Aao Transfer Form is not just a matter of paperwork; it is a vital step in ensuring that the patient receives the best possible treatment without unnecessary delays or misunderstandings.

Sample - 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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Form Information

Fact Name	Details
Purpose	The AAO Transfer Form facilitates the transfer of patient records between orthodontic providers.
Patient Information	It collects essential patient details, including name, birth date, and contact information.
Health Concerns	The form includes sections for special health concerns and patient/parent treatment concerns.
Treatment History	It documents the treatment plan, progress, and any appliances used during the active treatment phase.
Financial Information	Details on treatment fees, payment status, and potential changes in fees upon transfer are included.
Records for Transfer	The form specifies what records will be sent, including casts, x-rays, and treatment progress notes.
Authorization Requirement	Patient or guardian signature is required to authorize the release of records to a new provider.
State-Specific Forms	Different states may have specific regulations governing the transfer of patient records.
Governing Laws	In many states, the Health Insurance Portability and Accountability Act (HIPAA) governs patient record transfers.

Detailed Guide for Filling Out Aao Transfer

Completing the AAO Transfer form is essential for ensuring a smooth transition of orthodontic care when changing providers. The following steps will guide you through the process of filling out the form accurately.

Enter the date at the top of the form.
Fill in the "To" section with the name of the new orthodontist.
Complete the "From" section with your current orthodontist's name.
Provide the phone number, fax number, and email address of the current orthodontist.
Write the patient's name and birth date.
Indicate the patient's sex and Social Security number.
Include the patient's phone number and the responsible party's name.
State the relationship of the responsible party to the patient.
Fill in the home address, city, state/province, and zip code of the patient.
Document any significant history or TMD in the analysis section.
List patient or parent concerns regarding treatment.
Note any special health or history concerns.
Outline the treatment plan, including the chronology of treatment rendered.
Describe the treatment progress with a timeline.
Specify details about any fixed appliances, including type and manufacturer.
Indicate the type of bracket used and variations.
Provide dates for when bands and/or brackets were placed for both maxillary and mandibular arches.
List the bonding and cementing agents used.
Detail the current archwire size and type for both arches.
Include information about intraoral elastics, extraoral appliances, removable appliances, and clear tray appliances.
Assess patient cooperation regarding oral hygiene, headgear, elastics, clear trays, appointments, broken appliances, and attitude toward treatment.
Estimate active treatment time, including original and remaining time.
Provide recommendations for continued treatment and retention.
Add any additional comments relevant to the patient's treatment.
Indicate the financial status, including whether accounts are closed or open-ended.
Detail the fees for active treatment and any additional charges.
Document the status of available records for transfer, checking the appropriate boxes.
Sign and date the form as the orthodontist.
Complete the request to transfer records section, including signatures and names.

Obtain Answers 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. This ensures that the new orthodontist has all the necessary information to continue the patient's treatment without interruption.
Who needs to fill out the AAO Transfer Form?
The form should be completed by the patient or the patient's guardian. This includes providing details about the patient, their current treatment, and the new provider who will be taking over the care.
What information is required on the form?
The form requires various details, including:
- Patient's name and birth date
- Current and new orthodontist's contact information
- Patient's medical history and treatment progress
- Details about appliances used in treatment
- Financial information related to treatment fees
How does the transfer of records work?
Once the AAO Transfer Form is completed and signed, the current orthodontist will send the patient's records to the new provider. This process ensures that the new orthodontist is fully informed about the patient's treatment history and current status.
Will my treatment fees change after transferring?
Yes, it is possible that treatment fees may vary after transferring to a new orthodontist. The patient should expect that costs could increase, and changes in payment policies may occur.
What happens if my current orthodontist does not complete the transfer?
If the current orthodontist does not complete the transfer, it could delay the continuation of your treatment. It's important to communicate openly with both the current and new providers to ensure a smooth transition.
Are there any additional charges for record transfers?
There may be additional charges for record transfers, depending on the policies of the current orthodontist. It is advisable to ask about any potential fees before initiating the transfer process.
Can I request copies of my records?
Yes, you can request copies of your records. The form includes options to indicate whether record duplicates are sent upon request. Keep in mind that there may be an additional charge for this service.
What if I have concerns about my treatment during the transfer?
If you have concerns about your treatment during the transfer, it is essential to communicate these to both your current and new orthodontists. They can provide guidance and address any issues you may have.

Common mistakes

When filling out the AAO Transfer form, several common mistakes can lead to complications in the transfer process. One major error is leaving out essential patient information. Missing details like the patient's name, birth date, or social security number can delay the transfer and cause confusion.

Another frequent mistake is not providing accurate contact information for both the current and new orthodontist. If the phone number, email, or fax number is incorrect, it can hinder communication and the timely sharing of records.

People often forget to include the patient's treatment history. Failing to detail the treatment plan, progress, and any appliances used can leave the new provider without crucial context. This oversight may lead to misunderstandings and affect the continuity of care.

Additionally, many individuals neglect to indicate the status of financial arrangements. Not specifying whether fees are closed, open-end, or unpaid can create confusion regarding billing and payment responsibilities. This can result in unexpected charges for the patient.

Another common issue is not checking the box regarding record duplicates. Patients may assume that records will be sent automatically without confirming their preferences. This can lead to delays or additional charges for duplicate records.

People also sometimes overlook signing and dating the form. An unsigned or undated form may not be considered valid, causing further delays in the transfer process.

Lastly, failing to communicate specific concerns or suggestions for patient motivation can limit the new orthodontist's ability to effectively engage the patient. This can impact the overall treatment experience and outcomes.

Documents used along the form

When transferring orthodontic care, several documents accompany the AAO Transfer Form to ensure a smooth transition. Each document serves a specific purpose, providing essential information about the patient's treatment history and current status. Here’s a list of common forms and documents that are often used alongside the AAO Transfer Form.

Patient Consent Form: This document gives permission for the new orthodontist to access the patient's medical and treatment records. It confirms that the patient or guardian understands the implications of transferring care.
Financial Agreement: This outlines the financial responsibilities of the patient regarding the treatment. It includes details about payment plans, outstanding balances, and any changes in fees due to the transfer.
Treatment Summary: A brief overview of the patient's treatment history, including procedures completed, appliances used, and any significant events that occurred during treatment.
Medical History Form: This form provides a comprehensive overview of the patient’s medical background, including allergies, previous surgeries, and any ongoing health issues that may affect treatment.
Radiographs and Imaging Records: These include X-rays, CBCT scans, and other imaging studies that provide visual information about the patient's dental structure and treatment progress.
Progress Notes: A detailed record of each appointment, including observations made by the orthodontist, patient cooperation, and any adjustments made to the treatment plan.
Appliance Records: Documentation of any appliances used during treatment, including their types, placement dates, and any modifications made throughout the process.
Referral Letter: A letter from the current orthodontist explaining the reasons for the transfer and any specific recommendations for the new provider.
Contact Information: A document listing the contact details of both the current and new orthodontists to facilitate communication during the transfer process.

These documents work together to provide the new orthodontist with a complete picture of the patient's treatment journey. By ensuring all necessary paperwork is included, patients can help facilitate a seamless transition in their orthodontic care.

Similar forms

Patient Referral Form: Similar to the AAO Transfer Form, a patient referral form is used when a patient is referred from one healthcare provider to another. It includes patient details, medical history, and reasons for the referral.
Medical History Form: This document collects comprehensive information about a patient's past medical conditions and treatments, similar to the analysis section of the AAO Transfer Form.
Consent for Treatment Form: This form is used to obtain a patient's consent before treatment begins. It shares the purpose of treatment and expected outcomes, much like the treatment plan section of the AAO Transfer Form.
Insurance Information Form: This document gathers details about a patient’s insurance coverage. It is essential for financial arrangements, paralleling the financial section of the AAO Transfer Form.
Appointment Reminder Form: This form notifies patients about upcoming appointments and any necessary preparations. It serves a similar purpose to the patient cooperation section of the AAO Transfer Form.
Progress Notes: These notes track a patient’s treatment progress over time. They are akin to the treatment progress section of the AAO Transfer Form, documenting changes and developments.
Discharge Summary: This document summarizes a patient's treatment upon completion. It shares similarities with the recommendations for continued treatment in the AAO Transfer Form.
Patient Satisfaction Survey: This survey collects feedback from patients about their treatment experience. It relates to the patient concerns section of the AAO Transfer Form by addressing patient attitudes and suggestions.
Emergency Contact Form: This form collects information about who to contact in case of an emergency. It is similar to the responsible party section of the AAO Transfer Form.
Transfer of Records Request: This document is specifically used to request the transfer of medical records from one provider to another, closely mirroring the request to transfer records section of the AAO Transfer Form.

Dos and Don'ts

When filling out the AAO Transfer form, it is essential to ensure accuracy and clarity. Here are some important do's and don'ts to keep in mind:

Do provide complete and accurate patient information, including the full name, birth date, and contact details.
Do include a detailed analysis of the patient's treatment history and any concerns they may have.
Do specify the current treatment plan, including any appliances used and their status.
Do indicate any special health or history concerns that may affect treatment.
Don't leave any sections blank; incomplete forms may delay the transfer process.
Don't use abbreviations or shorthand that may not be understood by the receiving orthodontist.
Don't forget to sign and date the form to validate the transfer request.

By following these guidelines, you can help ensure a smooth transition for the patient's ongoing orthodontic care.

Misconceptions

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

This is not true. The form is designed for any patient who needs to change providers, whether due to relocation, a change in insurance, or other personal reasons. It facilitates a smooth transition for ongoing treatment.
Misconception 2: Completing the Aao Transfer form guarantees that the new orthodontist will accept the patient.

While the form helps in transferring records, acceptance by a new orthodontist is subject to their capacity and willingness to take on new patients. It’s advisable to confirm with the new provider before initiating the transfer.
Misconception 3: The Aao Transfer form is unnecessary if the patient has been seeing the same orthodontist for a long time.

Regardless of the duration of treatment, the form is essential for ensuring that all pertinent medical records and treatment plans are accurately conveyed to the new provider. This helps maintain continuity of care.
Misconception 4: Patients will always incur additional costs when transferring to a new orthodontist.

While it’s true that treatment fees may vary, not all transfers lead to increased costs. Some orthodontists may offer similar pricing, so it’s important for patients to discuss financial arrangements with their new provider.
Misconception 5: The Aao Transfer form is only about transferring records.

In addition to record transfer, the form includes vital information about the patient’s treatment history, progress, and any specific concerns. This comprehensive data is crucial for the new orthodontist to understand the patient’s needs and continue effective treatment.

Key takeaways

Fill out the AAO Transfer Form completely. Include all required information about the patient, such as name, birth date, and contact details.
Clearly state the patient's treatment history. This includes significant medical history and any concerns related to treatment.
Document the current treatment plan and progress. Be specific about appliances used and patient cooperation during treatment.
Be aware that transferring records may affect treatment costs. Patients should expect potential increases in fees when changing orthodontists.
Check the status of records before sending. Confirm whether duplicates are available and if records are enclosed or sent separately.
Ensure that the form is signed by the current orthodontist and the patient or guardian. This authorization is crucial for transferring records to the new provider.