If a doctor cannot continue treatment of a ClearCorrect case for any reason, the case may be officially transferred to another ClearCorrect provider by filling out the case transfer form. The receiving doctor must be a registered ClearCorrect provider.
You may email the form to a support rep or contact a provider services representative for assistance. It is perfectly alright to use two forms if needed.
Case transfer form
In order to transfer a patient to a new ClearCorrect doctor, you must complete and return this form, containing authorized signatures from both doctors.
This section is pretty self-explanatory, but please make sure that the information printed here is accurate and spelled correctly. We want to be absolutely sure that we are transferring the right patient to the right doctor. Your case number will be listed next to the patient's name on your Doctor's Portal account.
If you are the doctor who currently treats the patient, you will print and sign your name here. When you sign and date this form, you agree to the following:
- You are the currently registered ClearCorrect provider treating the case in question;
- You wish to transfer the case to another ClearCorrect provider;
- Once transferred, you will no longer be authorized to receive confidential medical information about this case from ClearCorrect;
- You are still legally responsible for any services performed before the transfer;
- You agree to ClearCorrect's current pricing, terms and conditions.
If you are the doctor to whom the case will be transferred, you will submit your information and sign here. Please include your name, your practice name and practice address as listed in our records in the Doctor's Portal. You must be a ClearCorrect provider in order to receive a transferred ClearCorrect case.
When you sign and date this form, you agree to the following:
- You are currently registered as a ClearCorrect provider;
- You wish to assume responsibility for all future treatment in the case specified above;
- The specified practice will receive any future phase shipments after the case transfer;
- You will be responsible for paying any outstanding costs for the case in question, regardless of when the costs were incurred;
- You may be asked to purchase more aligners if the treatment extends beyond the number of previously-purchased aligners;
- You agree to ClearCorrect's current pricing, terms & conditions.
In the event that a doctor has passed, lost their license, went to jail, skipped town, refuses to continue treating the patient or any other circumstance where the treating doctor cannot be reached, we still require a patient transfer form.
The patient can attempt to contact the dental office to see if there is someone managing the provider's legal or estate matters to get the form signed. Otherwise, we are unable to transfer the case, regardless of the circumstances.
480.193_en_A_01__10_19 (Case Transfer Form).pdf
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480.193_pt_br_A_01__10_19 (Case Transfer Form).pdf
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480.193_es_A_01__10_19 (Case Transfer Form).pdf
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480.193_fr_A_01__10_19 (Case Transfer Form).pdf
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480.193_it_A_01__10_19 (Case Transfer Form).pdf
900 KB Download
480.193_ja_A_01__10_19 (Case Transfer Form).pdf
1000 KB Download