Consents and Policies

Below, are copies of the consents and policies that you will be asked to sign electronically. Please review the information carefully and keep this information for your records.

Appointment Policy

We take great pride in the quality of care that we deliver. To maintain this high level of care, we have instituted appointment guidelines regarding cancellation /no-show/lateness. Compliance with this policy will allow patients to receive treatment promptly and efficiently, promoting optimal care and oral health.

• Once appointments are scheduled, patients are expected to attend each and every session at the appointed time.
• If you are going to be more than 15 minutes late for your scheduled appointment, please call to let us know so that we may notify your doctor.
• All cancellations must be communicated to the department 48 hours in advance or 72 hours in advance of a surgical and/or sedation procedure.
• If you cancel without proper notice or fail to show for 3 consecutive visits, you may be discharged from being provided care at the college.
• The College reserves the right not to reschedule patients who have been discharged for failing to show for prior scheduled appointments.
• I have read, understand and agree to abide by the aforementioned policy.

Touro Dental Health reserves the right to discontinue dental treatment at its sole discretion. Should treatment be terminated, any remaining credit balance for services not yet provided will be refunded. If you have a complaint that cannot be resolved at the student or faculty level, please contact the Director of Clinical Operations at 914-594-2707.

We appreciate your understanding and cooperation with this policy.

Patients Who Are Minors

A parent or legal guardian must accompany patients who are minors at every visit. This accompanying adult is responsible for payment of the account or must provide complete and accurate information about the guarantor on the insurance that will be billed.

Prescription Databases

Some insurance companies, pharmacies, or other entities send information on current and past patient prescriptions to electronic databases. Touro Dental Health’s electronic record system may query available prescription databases and receive such information concerning your past prescriptions. These queries may not identify all your current and past prescriptions. Therefore, it is important for you to keep an up-to-date list and to provide this information to your provider. By signing the consent, you give Touro Dental Health Permission to access these electronic databases.

Authorization for Release of Information

I hereby authorize and consent Touro College of Dental Medicine to release to government agencies, insurance carriers, or others who are financially liable for the dental care, all information needed to substantiate payment for such care, and permits others who are representatives thereof to examine and make copies of all records relating to such care and treatment. However, after disclosure has been made, it cannot be revoked retroactively to cover information released prior to revocation.

Photo and Video

Touro Dental Health will take or use existing photographs, audio and /or video recordings, x-rays, film, movies, or other images or recordings of patients for education and training, student portfolios, students research and presentations, etc.

Assignment of Benefits

I hereby assign and set over to the above named Touro College of Dental Medicine, Inc. sufficient monies and/or benefits to which I may be entitled from government agency insurance carrier or others who are financially liable for my dental, medical care to cover the costs of the care and treatment rendered to myself or my dependent in said practice. I understand that I am responsible for charges not covered by my insurance plan.

Email/Text Message Communications

As a patient, you agree that we may communicate with you by electronic means such as (but not limited to) email or text message. We will make every attempt to communicate over the Internet using a secure (encrypted) email/text messaging system. However, you must assume that there is no assurance of confidentiality when communicating via email /text messages. Touro Dental Health will not communicate health information that is specially protected under state and federal law (e.g., HIV/AIDS, substance abuse, mental health information) via email/texts.

Email communications are a two-way communication. However, responses and replies to emails sent to or received by either you or your health care provider may be hours or days apart.  This means that there could be a delay in receiving treatment for an acute condition.

Email messages on your computer, laptop, or other device have inherent privacy risks especially when your email access is provided through your employer or when access to your email messages is not password protected.

Email is sent at the touch of a button.  Once sent, an email message cannot be recalled or cancelled. Errors in transmission, regardless of the sender’s caution, can occur.  You can also help minimize this risk by using only the email address that you provide to our practice/ program/ provider.

To forward or process and respond to your email, individuals at Touro Dental Health other than your health care provider may read your email message. Your email message is not a private communication between you and your treatment provider. Neither you nor the person reading your email can see the facial expressions or gestures or hear the voice of the sender. Email can be misinterpreted.

At your health care provider’s discretion, your email message and all responses to them may become part of your medical record.

• I understand and agree to the following:
• I certify the email address provided on this request is accurate, and that I accept full responsibility for messages sent to or from this address.
• I have received a copy of the IMPORTANT INFORMATION ABOUT PATIENT EMAIL form, and I have read and understand it.
• I understand and acknowledge that communications over the Internet and/or using the email system may not be encrypted and may not be secure; that there is no assurance of confidentiality of information when communicated via email.
• I understand that all email communications may be forwarded to other providers for the purpose of providing treatment to me.
• I agree to hold Touro Dental Health and individuals associated with it harmless from any claims and liabilities arising from or related to this request to communicate via email.
• If you have an urgent or an emergency, you should not rely solely on provider / patient email to request assistance or to describe the urgent or emergency. Instead, you should act as though provider / patient email is not available to you and seek medical attention.
• I understand this consent will remain in force until I revoke it in writing.

By electronically signing these consents, listed above, I hereby state that I have read and understand these consent forms, and that I have been given the opportunity to ask questions, I might have, and that all my questions have been answered in a satisfactory manner.

Notice of Privacy Practices

This notice (Effective Date:  April 18, 2018) describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

• Get an electronic or paper copy of your medical record
  • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
  • We will provide a copy or a summary of your health information, usually within 10 days of your request. We may charge a reasonable, cost-based fee.
• Ask us to correct your medical record
  • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
  • We may say “no” to your request, but we’ll tell you why in writing within 60 days.
• Request confidential communications
  • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
  • We will say “yes” to all reasonable requests.
• Ask us to limit what we use or share
  • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
  • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
• Get a list of those with whom we’ve shared information
  • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
  • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
• Get a copy of this privacy notice
  • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a copy of the paper promptly.
• Choose someone to act for you
  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
  • We will make sure the person has this authority and can act for you before we take any action.
• File a complaint if you feel your rights are violated
  • You can complain if you feel we have violated your rights by contacting us using the information in the last paragraph.
  • You can file a concern with the Touro College and University System Compliance Hotline at 646-565-6330 or by emailing compliance@touro.edu.
  • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting hhs.gov/ocr/privacy/hipaa/complaints/.
  • We will not retaliate against you for filing a complaint.

Your Choices

• For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
• In these cases, you have both the right and choice to tell us to:
  • Share information with your family, close friends, or others involved in your care
  • Share information in a disaster relief situation
    
    If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
• In these cases we never share your information unless you give us written permission:
  • Marketing purposes
  • Sale of your information
  • Most sharing of psychotherapy notes
• In the case of fundraising:
  • We may contact you for fundraising efforts, but you can tell us not to contact you again.
  • If you wish to opt out of receiving fundraising communications, please contact Touro Office of Institutional Advancement at 646-565-6000 55025

Our Uses and Disclosures

We typically use or share your health information in the following ways.

• Treat you
  • We can use your health information and share it with other professionals who are treating you.
    
    Example: A doctor treating you for an injury asks another doctor about your overall health condition.
• Run our organization
  • We can use and share your health information to run our practice, improve your care, and contact you when necessary.
    
    Example: We use health information about you to manage your treatment and services.
• Bill for your services
  • We can use and share your health information to bill and get payment from health plans or other entities.
    
    Example: We give information about you to your health insurance plan so it will pay for your services.

How Else Can We Use or Share Your Health Information?

• We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research.
• We have to meet many conditions in the law before we can share your information for these purposes. Read more about your HIPAA rights.
• Help with public health and safety issues
  • We can share health information about you for certain situations such as:
    • Preventing disease
    • Helping with product recalls
    • Reporting adverse reactions to medications
    • Reporting suspected abuse, neglect, or domestic violence
    • Preventing or reducing a serious threat to anyone’s health or safety
• Do research
  • We can use or share your information for health research.
• Comply with the law
  • We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
• Respond to organ and tissue donation requests
  • We can share health information about you with organ procurement organizations.
• Work with a medical examiner or funeral director
  • We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
• Address workers’ compensation, law enforcement, and other government requests
  • We can use or share health information about you:
    • For workers’ compensation claims
    • For law enforcement purposes or with a law enforcement official
    • With health oversight agencies for activities authorized by law
    • For special government functions such as military, national security, and presidential protective services
• Respond to lawsuits and legal actions
  • We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
• In addition to the federal rules regarding health care privacy, we will follow New York State law. For example, we will obtain appropriate written consent from you before we share information concerning genetic information, HIV status, substance abuse treatment, and certain mental health information for purposes other than treating you or obtaining payment for services we provide to you.

Learn more about HIPAA Privacy Practices Notice.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.

Office of General Counsel
202 W. 43^rd Street, 11^th Floor
New York, New York 10036
compliance@touro.edu