Invisalign Patient Transfer Form

Invisalign Patient Transfer Form
Hidden Email
example@example.com
This Patient Transfer Form notifies and authorizes Align Technology, Inc. its representatives, successors, assigns and agents (together “Align”), to transfer all of the patient’s electronic Medical Records (described below) in its possession to New Treating Provider listed below.

“Medical Records” include, but are not limited to, x-rays, scans, reports, charts, prescriptions, medical history, photographs, findings, plaster models or impressions of teeth, diagnosis, medical testing, test results, billing, and other treatment records on file with Align for treatment purposes.
Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Date of birth*

DayMonthYear
In order to find your patient ID number please refer to your box or aligners:
Patient ID number*
Date Signed

DayMonthYear
Date
Date Signed

DayMonthYear
Date
Date Signed

DayMonthYear
Date
Date Signed

DayMonthYear
Date
This Patient Transfer Form authorizes correspondence with Align and any provider named above, verbally or in writing, regarding Medical Records and the transfer thereof, or other related information that may be (i) considered confidential under a national or state health, safety, or privacy code or ( ii) otherwise considered individually identifiable health information. 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 Patient Transfer Form. A copy of this Patient Transfer Form shall be considered as effective and valid as the original. This authorization shall be valid three years from the date I sign below.

I have read and understand the contents of this Patient Transfer Form:
Name

First NameLast Name
Patient's Signature*

Clear
Do you lack the legal capacity to sign? If so, a parent or legal guardian must also sign this form.*

YesNo
Legal Guardian Parent Name and Relationship
Parent / Guardian Signature

Clear
Should be Empty: