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The Invisalign Patient Transfer form is a critical document designed to facilitate the smooth transition of patients between dental practices utilizing Invisalign technology. This form enables the current treating doctor to officially release a patient’s records while also allowing the new doctor to accept the patient into their practice. Essential patient information, including the patient's name, identification number, gender, and date of birth, must be accurately filled out to ensure seamless processing. The form clearly outlines the responsibilities of both the current and new treating doctors, specifying that the former relinquishes control over treatment decisions, while the latter assumes liability for future treatment costs, including any necessary refinements or mid-course corrections. In situations where a patient seeks transfer without explicit consent from their current doctor, the form can still be processed, provided it carries the signatures of both the patient and the new doctor. Additionally, an authorization section for the release of medical records ensures that the new treating doctor receives comprehensive information needed for continued treatment, in compliance with regulations such as HIPAA. To complete the transfer, the form must be faxed to Align Technology's customer care, ensuring that all parties are informed and appropriately documented throughout the process.

Invisalign Patient Transfer Example

INVISALIGN PATIENT TRANSFER — AUTHORIZATION FORM

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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.

DOCTORS 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

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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

File Breakdown

Fact Title Details
Transfer Authorization The form allows the current doctor to authorize the transfer of a patient to a new Invisalign® doctor, including all ClinCheck® files.
Responsibilities of Doctors The current doctor relinquishes control over the patient, while the new doctor assumes full responsibility for future treatment and costs.
HIPAA Compliance Authorization includes the transfer of medical records in accordance with HIPAA regulations, ensuring confidentiality and proper handling of personal health information.
State-Specific Requirements Different states may have specific laws regarding patient transfers. For instance, California's Business and Professions Code § 654.2 governs such transfers, ensuring patient rights are upheld.

Guide to Using Invisalign Patient Transfer

Completing the Invisalign Patient Transfer form is essential for ensuring that the transfer of treatment between doctors goes smoothly. Follow these steps carefully to fill out the required information accurately.

  1. Start by entering the patient's full name, including their last, first, and middle names in the designated area.
  2. Next, provide the patient number and the patient's date of birth in the mm/dd/yyyy format.
  3. Indicate the patient's gender by checking the box for either Female or Male.
  4. For the current doctor section, write the reason for transfer in the provided space.
  5. Print the current treating doctor's name clearly.
  6. Below, the current treating doctor must sign the form and include their practice name and practice address.
  7. For the new doctor section, print the doctor's name, their Invisalign username and then provide their signature.
  8. Then, have the new doctor fill in their practice name and practice address.
  9. If applicable, a patient or new doctor can sign the section without the current doctor.
  10. Finally, fax the completed form to Align Customer Care at 408-790-0670.

Get Answers on Invisalign Patient Transfer

What is the purpose of the Invisalign Patient Transfer form?

The Invisalign Patient Transfer form is designed to facilitate the transfer of a patient’s treatment and medical records from one Invisalign-trained doctor to another. This process includes the patient’s ClinCheck files and any relevant medical history. The form serves as an official authorization document to ensure that both the current and new doctors can manage the patient's ongoing treatment effectively.

What information is required on the form?

When completing the Invisalign Patient Transfer form, specific patient and doctor information is necessary. Patients must provide:

  1. Name (last, first, middle)
  2. Patient number
  3. Date of birth
  4. Gender
  5. Reason for transfer

Doctors must also include their names, practice names, and addresses. Both the current and new treating doctors must sign the form to acknowledge their respective responsibilities in the transfer process

.

What happens after the form is submitted?

Once the form is completed and faxed to Align Technology Customer Care at 408-790-0670, the transition process begins. Align Technology facilitates the transfer of medical records between the doctors. Patients should expect that all relevant medical records, including x-rays and treatment notes, will be accessible to the new doctor. However, it is important to note that the current doctor remains responsible for any open balance incurred prior to the transfer.

Can a patient initiate a transfer without the current doctor's authorization?

Yes, in certain situations, a patient may initiate a transfer without their current doctor's authorization. Scenarios include dissatisfaction with current treatment or a doctor's unavailability. In such cases, both the patient and the new doctor can sign the form, thereby allowing the transfer process to proceed. It is crucial for both doctors to understand that they will indemnify Align Technology against any potential liabilities arising from this transfer.

Common mistakes

Filling out the Invisalign Patient Transfer form may seem straightforward, but many individuals often make mistakes that can delay the transfer process. One common error is leaving out crucial patient information, such as the patient's last name, first name, or date of birth. Each of these details is vital for accurately identifying the patient and ensuring that their records are transferred correctly. Without this information, the request may be rejected or lead to confusion later on.

Another frequent mistake involves the omission of the patient number. This number serves as a unique identifier for the patient within the Invisalign system. When it is not included, it can hinder the new doctor's ability to access the patient's ClinCheck® files. Remember, accuracy is key; be sure to double-check this information.

Many individuals also fail to provide the reason for the transfer. While it might seem unnecessary, this information helps both Align Technology and the new treating doctor understand the context of the transfer. Providing this detail supports a smoother transition and clarifies the motivations behind the transfer.

Signatures on the form need careful attention. The current treating doctor must sign the form to authorize the transfer. Occasionally, people either overlook this requirement or mistakenly believe that it’s sufficient for only the new doctor to sign. This can lead to unnecessary delays, as a lack of authorization from the current provider can complicate the transfer process.

Additionally, some individuals neglect to include the date next to their signatures. Including the date is essential as it signifies the moment the authorization was granted. Without it, the form may be deemed incomplete and can create confusion about when the transfer took place.

Incorrectly filling out the practice name or address can also cause problems. The form requires precise information about both the current and new doctors' practices. Errors in this information can lead to miscommunication and hinder the transfer process. Therefore, it's essential to review all written details for accuracy.

Lastly, it’s worth noting that the section about medical records release often gets overlooked. While it’s easy to focus on the patient transfer itself, authorizing the release of medical records is equally important. This section ensures that the new doctor receives all necessary information to provide effective treatment. Incomplete or absent permissions can prevent timely access to vital patient records.

In summary, careful attention to detail when filling out the Invisalign Patient Transfer form is crucial. By avoiding these common mistakes, patients can ensure a smoother transition and continued quality care.

Documents used along the form

In addition to the Invisalign Patient Transfer form, there are several other important documents and forms commonly utilized in the patient transfer process. Each serves a specific purpose and contributes to ensuring a smooth transition of patient care between doctors. Below is an overview of these documents.

  • Informed Consent Form: This document provides patients with information about the treatment process, associated risks, and benefits. Patients must sign it to indicate their understanding and acceptance of the treatment plan.
  • Patient History Form: This form gathers essential medical and dental history from the patient. It includes information about past treatments, allergies, and medications, helping the new doctor understand the patient's background.
  • Financial Responsibility Form: This document outlines the patient's financial obligations regarding their treatment. By signing it, the patient acknowledges understanding their responsibilities for costs related to services rendered.
  • Authorization for Release of Information Form: This form grants permission for the sharing of medical information between the current and new treating doctors. It is essential for ensuring continuity of care and access to necessary records.
  • Referral Letter: A letter written by the current doctor that details the patient's treatment history and specific needs. It helps the new doctor assess the patient’s case and plan appropriate treatment.
  • Prescription Records: This document contains records of any prescriptions previously issued to the patient. It ensures that the new treating doctor is aware of the medications the patient has been prescribed.
  • Privacy Practices Acknowledgment: This form informs patients about how their health information will be handled and protected. By signing, patients acknowledge their understanding of privacy practices as mandated by legal regulations.
  • Financial Aid Application (if applicable): If a patient needs financial assistance for treatment, this form can help initiate a request for support. It collects necessary information to evaluate eligibility for aid programs.

Each of these documents plays a crucial role in facilitating a comprehensive and effective patient transfer while ensuring compliance and communication between healthcare providers. Collectively, they support a seamless transition for the patient, reinforcing the commitment to high-quality care.

Similar forms

The following documents share similarities with the Invisalign Patient Transfer form. Each one is designed to address the transfer or release of patient information in various healthcare contexts. They generally contain elements such as patient consent, information release, and responsibilities of the involved parties.

  • Medical Records Release Form: This document allows a patient to authorize the release of their medical records from one healthcare provider to another. Like the Invisalign Patient Transfer form, it requires patient consent and typically details the specific records being transferred.
  • Patient Referral Form: Used by healthcare providers to refer patients to specialists, this form outlines the reason for the referral and may include medical history. Similar to the Invisalign form, it ensures that pertinent patient information is shared with the new provider.
  • Informed Consent Form: Patients sign this form to acknowledge understanding of medical procedures, including risks and benefits. Both it and the Invisalign Patient Transfer form require patient acknowledgment of responsibilities and any potential outcomes of treatment changes.
  • Transfer of Care Agreement: This document outlines responsibilities between the outgoing and incoming healthcare providers during a patient transfer. It parallels the Invisalign form by emphasizing the need for mutual consent for the transfer of patient responsibilities.
  • Pediatric Patient Transfer Form: Specifically for transferring care of a minor from one healthcare provider to another, it requires both parental consent and new provider acknowledgment. Similar to the Invisalign form, it highlights the necessity of clear communication regarding patient treatment.
  • Psychiatric Patient Transfer Form: This is used to manage the transfer of a patient’s mental health care between providers. Like the Invisalign form, it includes sections for current and new providers to sign, indicating that they understand the transfer of responsibilities.
  • Durable Power of Attorney for Healthcare: This legal document allows a designated person to make healthcare decisions on behalf of the patient. It shares similarities with the Invisalign form when it comes to authorizing one party to act in the best interest of another regarding medical care.
  • Authorization for Release of Information (ROI): This is often used in a variety of care settings to obtain consent for sharing patient information with third parties. Much like the Invisalign Patient Transfer form, it emphasizes the need for authorization from the patient.
  • Health Information Exchange (HIE) Consent Form: This form grants permission for sharing a patient’s health records between different healthcare facilities. It is akin to the Invisalign Patient Transfer form in that both facilitate the sharing of important patient information across different providers.

Dos and Don'ts

When filling out the Invisalign Patient Transfer form, certain practices can help ensure the process goes smoothly. Here are six important dos and don’ts.

  • Do include accurate patient information, such as full name and date of birth.
  • Do sign the form in the designated area to authorize the transfer.
  • Do fax the completed form to the designated number: 408-790-0670.
  • Don’t forget to include both the transferring and accepting doctor's signatures, if possible.
  • Don’t submit the form without confirming all fields are correctly filled out.
  • Don’t use a photocopy for submission; the original form is preferred.

Adhering to these guidelines will make the transfer process more efficient and effective.

Misconceptions

  • Misconception 1: The form can be submitted without the current doctor’s consent.
  • This is incorrect. While both the current and new doctors ideally need to sign the form, in certain situations, the patient can transfer without the current doctor’s approval. However, this may complicate matters and should be approached with caution.

  • Misconception 2: The patient will no longer have financial obligations after transferring.
  • This misconception is widespread. In reality, the current doctor remains responsible for any outstanding balances accumulated before the transfer. Transferring to a new doctor does not erase these financial obligations.

  • Misconception 3: Align Technology, Inc. is liable for treatment outcomes after a transfer.
  • This assumption is false. Both the current and new doctors acknowledge that Align Technology, Inc. holds no responsibility for any costs or liabilities that arise from the decision to transfer the patient. This must be clearly understood by both parties.

  • Misconception 4: The patient’s medical records can only be transferred to a new doctor with the patient’s signature.
  • While the patient’s signature is generally required, the form can also be signed by the new doctor to facilitate the transfer. This flexibility helps ensure that patients can receive timely treatment, despite potential barriers.

Key takeaways

Completing the Invisalign Patient Transfer form requires attention to detail and clear communication. Here are six key takeaways to ensure a successful transfer process.

  • Authorization Requirements: Both the current treating doctor and the new treating doctor should ideally sign the form to ensure a smooth transition. This validates the transfer and maintains patient trust.
  • Patient Responsibility: The current doctor must recognize that they remain responsible for any outstanding balances related to the patient’s treatment before the transfer occurs.
  • Documentation Submission: The completed form must be faxed to Align Technology at 408-790-0670. Failing to send it correctly could delay the transfer process.
  • Medical Records Authorization: The patient must authorize the release of their medical records to the new doctor. This includes all relevant documentation necessary for ongoing treatment.
  • Liability Agreement: Both doctors agree to indemnify Align Technology, which protects the company from liabilities arising from the transfer process. This is a critical consideration to ensure legal clarity.
  • Validity Period: The authorization remains valid for three years from the date of signing, allowing flexibility in how long the new doctor can access the medical records.

Considering these points can help streamline the patient transfer process and facilitate better treatment outcomes.