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Download Aao Transfer Template

The AAO Transfer Form is a document used to facilitate the transfer of patient records between orthodontic providers. This form ensures that the new orthodontist receives comprehensive information about the patient's treatment history, current status, and any specific concerns. By providing detailed insights, it helps maintain continuity of care for patients undergoing orthodontic treatment.

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Content Overview

The Aao Transfer form plays a crucial role in the seamless transition of orthodontic care when a patient needs to change providers. This form is designed for patients currently undergoing active treatment, ensuring that their new orthodontist receives all necessary information to continue their care without interruption. Key elements of the form include patient demographics, treatment history, and any specific concerns or recommendations from the current orthodontist. It captures vital details such as the patient's name, birth date, and social security number, along with an analysis of their treatment progress and appliances used. Moreover, the form outlines the financial aspects of the treatment, highlighting any unpaid balances or changes in fees that may occur due to the transfer. It also emphasizes the importance of timely record transfers to maintain continuity in care, ensuring that the new provider is fully informed about the patient's treatment plan and history. By facilitating communication between the current and new orthodontists, the Aao Transfer form ultimately supports the patient’s ongoing journey toward achieving their orthodontic goals.

Key takeaways

When filling out the AAO Transfer form, keep the following key points in mind:

Patient Information: Ensure all personal details, including the patient's name, birth date, and contact information, are accurately filled out.
Health History: Provide a comprehensive analysis of the patient's medical history and any special health concerns that may affect treatment.
Treatment Plan: Clearly outline the treatment plan, including a chronology of treatment rendered to date. This helps the new provider understand the patient's current status.
Appliance Details: Specify the types of appliances used, their manufacturers, and any relevant dates. This information is crucial for continuity of care.
Patient Cooperation: Document the patient’s cooperation level regarding oral hygiene, appointments, and adherence to treatment recommendations.
Financial Information: Clearly indicate the financial status, including any unpaid amounts and the balance of the original quoted fee.
Record Transfer: Check the appropriate status of records being transferred. Indicate whether records are enclosed or sent under separate cover.
Signature Requirement: The form must be signed by the current orthodontist and the patient or guardian to authorize the transfer of records.

Completing this form accurately and thoroughly ensures a smooth transition for the patient to their new orthodontist.

Guide to Writing Aao Transfer

Filling out the AAO Transfer Form is an important step when transitioning orthodontic care. This form ensures that the new provider has all the necessary information to continue treatment seamlessly. Follow the steps below to complete 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, Fax, and Email of the current orthodontist.
Input the Patient's name and Birth date.
Specify the Sex and Social Security # of the patient.
Fill in the Phone number and the Responsible party details.
Indicate the Relationship to the patient and complete the Home address section.
Detail the City, State/Province, and Zip code.
In the ANALYSIS section, provide significant history and TMD information.
List any PATIENT/PARENT CONCERNS RE: TX.
Note any SPECIAL HEALTH OR HISTORY CONCERNS.
Outline the TREATMENT PLAN, including a chronology of treatment rendered.
Document the TREATMENT PROGRESS with a chronology of treatment rendered.
Fill in details about APPLIANCES, including types and relevant dates.
Assess PATIENT COOPERATION regarding oral hygiene and appointments.
Estimate the ACTIVE TX TIME and provide recommendations for continued treatment.
Include RECOMMENDATIONS FOR RETENTION and any additional comments.
Complete the FINANCIAL section, indicating the status of fees and payments.
Check the appropriate status of records for transfer and indicate if records are enclosed.
Finally, have the current orthodontist sign and date the form.

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Form Preview 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 ______________________________

Documents used along the form

The AAO Transfer form is an essential document used in the process of transferring a patient’s orthodontic records from one provider to another. Alongside this form, several other documents may be necessary to ensure a smooth transition and continuity of care. Below is a list of some commonly used forms and documents that accompany the AAO Transfer form.

Patient Authorization Form: This document grants permission for the current orthodontist to release the patient’s records to the new provider. It typically includes the patient’s name, the name of the current and new orthodontist, and the signature of the patient or guardian.
Financial Agreement: This form outlines the financial arrangements made between the patient and the current orthodontist. It details any outstanding balances, payment plans, and the expected costs associated with the treatment.
Power of Attorney Form: In cases where the patient may be unable to make decisions regarding their treatment, a https://smarttemplates.net Power of Attorney form can authorize someone else to act on their behalf, ensuring that their preferences and needs are respected during the transfer process.
Treatment History Summary: This summary provides an overview of the patient’s treatment progress, including significant milestones, challenges faced, and any changes made to the treatment plan. It helps the new provider understand the patient's journey so far.
Diagnostic Records: These records may include x-rays, photographs, and dental casts that document the patient's orthodontic condition. They are crucial for the new orthodontist to assess the current situation and plan further treatment.
Referral Letter: A referral letter may be included, explaining the reasons for the transfer and any specific concerns or recommendations from the current orthodontist. This letter can help guide the new provider in their approach.
Consent for Treatment: This document confirms that the patient or guardian understands and agrees to the treatment plan proposed by the new orthodontist. It is important for establishing clear communication and expectations.
Patient Information Form: This form collects updated personal and medical information about the patient. It ensures that the new provider has the most current data, including any changes in health status or contact details.

In summary, the successful transfer of orthodontic care involves several key documents. Each of these forms plays a vital role in ensuring that the new provider has all necessary information to continue treatment effectively. This collaborative approach not only supports the patient’s ongoing care but also fosters clear communication between healthcare providers.