AAO Transfer Form at a glance
What it is: The AAO Transfer Form, for a patient in active treatment, is a request to transfer records to a new provider.
Who signs: Check appropriate status of records: Record duplicates sent upon request (may be an additional charge to patient), Records enclosed, and Records sent under separate cover, each Yes or No. The Orthodontist signs on the Signature line and enters the Date. The Patient or Guardian signs on the Signature line, enters the Date, then Print Name and the Relationship to Patient.
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.
A filled-in AAO Transfer Form example: a transfer form for a patient in braces
How to fill out AAO Transfer Form, box by box
Date, To, From, Phone, Fax and Email
Enter the Date, then To, then From, then the Phone, Fax and Email.
The patient and the responsible party
Enter the Patient's name, Birth date and Sex, then the Social Security # and Phone.
Enter the Responsible party and Relationship, then the Home address, City, State/Province and Zip code.
Analysis, concerns, treatment plan and progress
Write the ANALYSIS (Including significant history & TMD), the PATIENT/PARENT CONCERNS RE: TX and the SPECIAL HEALTH OR HISTORY CONCERNS.
Write the TREATMENT PLAN and the TREATMENT PROGRESS, each Including chronology of treatment rendered.
Appliances
For the Fixed appliance under APPLIANCES, enter the Type, Manufacturer, Type of bracket and Variations, the Date bands and/or brackets placed (Max and Mand), the Bonding Agent and Cementing Agent, and the Current archwire size and type (Max and Mand).
For Intraoral elastics, enter dates initiated, size and direction, and Hours requested.
For an Extraoral appliance and a Removable appliance, enter the Type and dates initiated and the Hours requested.
For a Clear tray appliance, enter the Manufacturer, Total trays, Trays delivered, Change interval and Case/Patient number.
Patient cooperation
Under PATIENT COOPERATION, enter Oral hygiene and Headgear.
Elastics, clear trays and appointments
Enter Elastics, Clear trays, Appointments and Broken appliances, then the Patient's attitude toward treatment and Suggestions for patient motivation.
Active TX time estimates
Under ACTIVE TX TIME ESTIMATES, enter Original and Remaining.
Recommendations
Write the RECOMMENDATIONS FOR CONTINUED TREATMENT, the RECOMMENDATIONS FOR RETENTION and the ADDITIONAL COMMENTS.
Financial
Under FINANCIAL, enter Closed, Open End (Fixed) and Other, then Fees: Active and Extras, and Terms.
Enter the Third party payment, Total charges before transfer, Total amount paid before transfer, Unpaid amount still owed transferring office, and 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.
Available records for transfer
Under AVAILABLE RECORDS FOR TRANSFER, enter the Initial Date and Progress Date for Casts, Ceph, Tracings, Panoramic, CBCT, Intra-oral scan, Intraoral x-rays, Facial photos and Intraoral photos, and the Articulator type for Casts.
I authorize Dr. to release all records
Write the name after I authorize Dr., the patient's name after to release all records of, and the new provider's name after for the purpose of continuation of treatment by Dr.
More rules for AAO Transfer Form
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.
Common questions about AAO Transfer Form
Are there fees?
For most people who transfer during their orthodontic treatment, the total treatment cost is likely to increase.
Sources
[1] AAO Transfer Form, Patient in Active Treatment (the Official source link on this page).
