Case Transfer Form

For information regarding a case transfer form, refer to the following:

• Case Transfer Form
• Patient Info 
• Current Doctor 
• New Doctor

Case Transfer Form

If a doctor cannot continue treatment of a ClearCorrect case for any reason, or at the discretion of the patient, 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 Customer Care representative for assistance. It is perfectly acceptable to use two forms if needed.

In order to transfer a patient to a new ClearCorrect doctor, you must complete and return this form. The form must contain the authorized signature from the new doctor.

Patient Info 

Please ensure 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. If the current doctor initiated the transfer, the case number can be found next to the patient's name on the Doctor Portal account. If the transfer is being initiated by the new doctor, they can find the case number from the laser marking on the patient's aligner or on an aligner bag.

Current Doctor

If the current doctor is initiating the transfer, they may print the form and complete the patient's information and current doctor's name. The Case Transfer Form does not require the current doctor's signature and no action is required on their part.

New Doctor

If you are the doctor that will be taking on the transferred case, you will submit the form including the patient's information, your information and signature. The practice name and practice address must be the same as listed in our records in the Doctor 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 within the form.
• The specified practice will receive any future phase shipments after the case transfer is complete. 
• You will be responsible for paying any outstanding fees for the case in question, regardless of when the fees were incurred.
• You may be asked to purchase additional aligners if the treatment extends beyond the number of previously purchased aligners.
• You agree to ClearCorrect's current pricing, terms & conditions.