Invisalign Patient Transfer Authorization Form free printable template

Name: Invisalign Patient Transfer Authorization Form - Fill Online, Printable, Fillable, Blank - pdfFiller
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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. 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 2 of 2 AUTHORIZATION TO RELEASE MEDICAL RECORDS The individual set forth above or a representative thereof is This Release also authorizes correspondence with Align or New hereby authorizing the release of their personal medical records Doctor orally or in writing regarding such Medical Records and from doctor the transfer thereof or other medical information that may be i to doctor considered confidential...under a state health or safety code or ii considered individually identifiable health information as use by New Doctor in treatment with products from Align defined by the Health Insurance Portability and Accountability Technology Inc. Act HIPAA. 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 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. Invisalign Username Signature of New Treating Doctor 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.

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Invisalign Patient Transfer Authorization Form Guide

What is the Invisalign patient transfer authorization form?

The Invisalign patient transfer authorization form is a crucial document that facilitates the transfer of patient records and treatment responsibility from one orthodontist to another. Its importance lies in ensuring a seamless transition for continuing care while maintaining supervision and management of the patient's orthodontic treatment.

Why is the transfer process important?

Ensures that patients receive uninterrupted treatment, as the new doctor will have access to their records.
Protects patient information during the transfer, complying with legal regulations.
Defines the roles of the current treating doctor, new treating doctor, and Align Technology Inc.

What are the key sections of the authorization form?

Captures essential details about the patient for identification.
Details the current doctor's consent to allow the transfer of care.
Confirms the new doctor's agreement to take on the patient.
Ensures necessary parties have signed to validate the transfer.

How do fill out the patient information section?

Use the full legal name to avoid discrepancies in records.
These details are crucial for accurate medical record management.
This unique identifier helps maintain continuity and accuracy in records.

What are the current doctor transfer release details?

The current provider must confirm their authorization signature, indicating they relinquish treatment responsibilities.
This involves acknowledging that control over treatment decisions is being transferred.
Current doctors should be aware of any ongoing responsibilities even post-transfer.
These can include relocation, dissatisfaction with current treatment, or a need for specialized care.

What about the acceptance of the patient by the new doctor?

The new doctor is responsible for reviewing the patient's treatment plan and ensuring all necessary information is gathered.
New doctors should be clear about any charges related to patient care initially or ongoing.
A signature from the new doctor indicates a commitment to provide care and accept responsibility.

How to submit the completed form?

Patients can fax or email the form according to their doctor's preferences.
Ensure the new doctor has received the form by following up after submission.
Have a plan in place to resolve disputes, such as direct communication between the old and new doctors.

What resources are available for further assistance?

They can provide guidance and support regarding the transfer process.
pdfFiller offers templates and resources to simplify document management.
Understanding legal implications is essential in patient transfers to avoid potential pitfalls.

Frequently Asked Questions about invisalign case transfer form

What should I do if my current doctor refuses to sign the authorization form?

If your current doctor refuses to sign, it's important to have a conversation with them to understand their concerns. You may also seek legal advice or contact Align Technology Inc. for support.

How is patient confidentiality maintained during the transfer?

The Invisalign patient transfer authorization form includes sections that ensure your sensitive information is handled according to confidentiality laws. It's crucial to only interact with authorized parties during the transfer.

What if there are complications during the transfer?

In case of complications, communicate directly with both doctors to resolve issues. If necessary, legal advice may be sought to navigate disputes effectively.

Can I track the status of my transfer process?

While tracking is not formally provided, following up with both the current and new doctor is encouraged to ensure a smooth transition.

What happens to my treatment records after the transfer?

Your treatment records should be transferred to the new provider. Ensure that the new doctor has received all the necessary documentation for continuity of care.