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.