Invisalign Patient Transfer PDF Form - FormsPal

Invisalign Patient Transfer Form PDF Details

If you are a new Invisalign patient, or are about to begin treatment, you will need to complete and submit the Invisalign Patient Transfer Form. This form allows your previous dental provider to share important information about your treatment history with your new Invisalign provider. You can find the form on the Align Technologies website, and it must be submitted before you can start your Invisalign treatment. Completing and submitting the form is easy, and it's important that you do so in order to ensure a smooth transition into your new Invisalign treatment plan.

Below, you will see quite a few specifics of invisalign patient transfer form PDF. You may find out its length, the actual time to fill out the form, the fields you should fill in, and so on.

Question	Answer
Form Name	Invisalign Patient Transfer Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	30
Avg. time to fill out	6 min 30 sec
Other names	patient transfer authorization form, invisalign patient form, release invisalign, invisalign form

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Form Preview Example

INVISALIGN PATIENT TRANSFER — AUTHORIZATION FORM	1 OF 2

FAX COMPLETED FORM TO 408-790-0670

Please read below and sign in corresponding area to authorize Align Technology, Inc. to transfer patient:

PATIENT INFORMATION

NAME (LAST, FIRST, MIDDLE)

PATIENT #

/ /

Gender: Female

Male

Date of Birth mm/dd/yyyy	Patient Number

RELEASE OF PATIENT (CURRENT DOCTOR)

Transfer this patient out of my Invisalign® Doctor Site including the patient’s ClinCheck® files. I understand that by doing so, I relinquish all control of this patient to the new treating doctor. Align Technology, Inc. shall not be responsible for any cost, liability or obligation resulting from my decision to transfer the patient to another doctor for treatment. I acknowledge that I am still responsible for any open balance incurred in this patient’s treatment prior to the transfer.

Reason for Transfer

Doctor’s Name (Please print)

Signature of Current Treating Doctor

Practice Name

Practice Address

ACCEPTANCE OF PATIENT (NEW DOCTOR)

Transfer the patient into my Invisalign® Doctor Site including the patient’s ClinCheck® files. I understand that by doing so, I accept and will assume full responsibility of any future charges incurred due to Mid-Course Correction, Treatment costs, Patient Refinement fees and any replacement Aligner/Retainer fees. Align Technology, Inc. shall not be responsible for any cost, liability or obligation resulting from my decision to accept the patient for treatment.

DOCTOR’S NAME

Invisalign Username

Signature of New Treating Doctor

Practice Name

Practice Address

(Customer Care Representative handling transfer)

*In order to complete a Patient Transfer, it is desired that both the Invisalign® Trained Doctor that is transferring the patient, and the Invisalign® Trained Doctor that is accepting the patient, sign the transfer. However in some instances patients desire to transfer without authorization from their current doctor due to something that occurred during treatment, inability to locate the doctor or other similar reasons. As a result Align will accept a case transfer request if signed by patient and new doctor only. Each doctor agrees to indemnify, defend and hold harmless Align Technology, Inc. and its affiliates from and against any and all damages, losses, settlement payments, obligations, liabilities, penalties, claims, actions or causes of action, encumbrances and reasonable costs and expenses (including, without limitation, attorneys’ fees and costs of investigation) suffered, sustained, incurred or paid by Align Technology, Inc. arising from this transfer. This form must be faxed to Align Customer Care at 408-790-0670.

Align Technology, Inc. (888) 822-5446

WWW.INVISALIGN.COM

INVISALIGN PATIENT TRANSFER — AUTHORIZATION FORM	2 OF 2

AUTHORIZATION TO RELEASE MEDICAL RECORDS

PATIENT INFORMATION

NAME (LAST, FIRST, MIDDLE)

PATIENT #

/ /

Gender: Female

Male

Date of Birth mm/dd/yyyy	Patient Number

The individual set forth above, or a representative thereof, is hereby authorizing the release of their personal medical records, from doctor __________________________________________

to doctor ____________________________________________,

an Invisalign® Trained doctor (hereinafter “New Doctor”) for use by New Doctor in treatment with products from Align Technology, Inc.

This Authorization to Release Medical Records (“Release”) includes, but is not limited to, x-rays, reports, charts, medical history, photographs, findings, plaster models or impressions of teeth, prescriptions, diagnosis, medical testing, test results, billing, and other treatment records in my doctor’s possession (“Medical Records”).

This Release also notifies and authorizes Align Technology, Inc., its representatives, successors, assigns and agents (collectively “Align”) to transfer all Medical Records for the individual set forth above in its possession to New Doctor, wherein New Doctor will have electronic access to such records.

Signature

Print Name

Address

City, State, Zip

Date

This Release also authorizes correspondence with Align or New Doctor, orally or in writing, regarding such Medical Records and the transfer thereof, or other medical information that may be (i) considered confidential under a state health or safety code, or

(ii)considered “individually identifiable health information” as defined by the “Health Insurance Portability and Accountability Act” (HIPAA).

I will not, nor shall anyone on my behalf, have any rights of approval, claims of compensation, or seek or obtain legal, equitable or monetary damages or remedies arising out of use of my Medical Records that comply with the terms of this Release. A photocopy of this Release shall be considered as effective and valid as the original. This authorization shall be valid three years from its date. I have read and understand the contents of this Release.

This form must be faxed to 408-790-0670.

Witness

Print Name

If signatory is under 21, the parent or Legal Guardian must also sign below to signify agreement

Signature of Parent/Guardian

Align Technology, Inc. (888) 822-5446

WWW.INVISALIGN.COM

© 2010 Align Technology, Inc. All rights reserved. | F16014, Rev. C

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invisalign transfer form gaps to complete

Enter the demanded details in the space Doctors, Name In, vis, align, Username Signature, of, New, Treating, Doctor Practice, Name Practice, Address and Align, Technology, Inc, WWW, IN, VIS, ALIGN, COM

Completing invisalign transfer form part 2

The system will require particulars to quickly fill up the section PATIENT, INFORMATION Name, Last, First, Middle Gender, Female cid, Male cid, PATIENT, DateofBirth, mm, dd, yyyy Patient, Number from, doctor to, doctor Technology, Inc and Act, HIP, A, A

invisalign transfer form PATIENTINFORMATION, NameLastFirstMiddle, GenderFemale, cidMale, cid, PATIENT, DateofBirthmmddyyyy, PatientNumber, fromdoctor, todoctor, TechnologyInc, and ActHIPAA fields to complete

You will need to define the rights and obligations of both sides in part Signature, Print, Name Address, City, State, Zip Date, Witness, Print, Name Signature, of, Parent, Guardian and Align, Technology, Inc, WWW, IN, VIS, ALIGN, COM

Filling in invisalign transfer form step 4

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