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Request to Transfer Records to New Provider

When a patient moves, or, for other reasons, there is a necessity to change orthodontists during the course of ongoing orthodontic treatment, it is highly advantageous for all involved parties that the transfer be as prompt and convenient as possible. Of paramount importance is the identification of an orthodontist who will accept the patient and successfully complete the treatment.

The American Association of Orthodontists represents nearly ninety percent of the orthodontic specialists in the U.S. and Canada. Your current doctor is a member and will assist you in finding a qualified orthodontist.

It is necessary that your records be transferred to assure that the receiving orthodontist is knowledgeable of your orthodontic condition(s), orthodontic treatment goals, the current treatment plan, and related financial arrangements.

This patient/parent has been advised that orthodontic treatments vary widely throughout the country and the world and it is reasonable for them to expect that a transfer may increase treatment fees and may involve changes in payment policies. For most people who transfer during their orthodontic treatment, the total treatment cost is likely to increase.

To facilitate the transfer of these records, it is necessary that you complete the following:

I authorize Dr. Won-Woo Jonathan Park to release all records of for the purpose of continuation of treatment by the new orthodontist.

Name of New Orthodontist: (new provider’s name)

Address:

City:

State/Province:

Zip Code:

Phone:

Name:

Relationship to Patient:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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May 20, 2023 7:37 am MST

Request to Transfer Records to New Provider Uploaded by Won-Woo Jonathan Park - forms@ooliortho.com IP 70.163.243.141

May 21, 2023 8:08 am MST

OoLi Team - forms@ooliortho.com added by Won-Woo Jonathan Park - forms@ooliortho.com as a CC'd Recipient Ip: 70.163.243.141

May 21, 2023 8:08 am MST

MJ Cindy Kim - cindy@ooliortho.com added by Won-Woo Jonathan Park - forms@ooliortho.com as a CC'd Recipient Ip: 70.163.243.141

May 21, 2023 8:18 am MST

OoLi Team - forms@ooliortho.com added by Won-Woo Jonathan Park - forms@ooliortho.com as a CC'd Recipient Ip: 70.163.243.141

May 21, 2023 8:18 am MST

MJ Cindy Kim - cindy@ooliortho.com added by Won-Woo Jonathan Park - forms@ooliortho.com as a CC'd Recipient Ip: 70.163.243.141