WIXLIB

Providing Radiographs or X-RaysIf you have had high-quality diagnostically acceptable radiographs takenwithin the last 3 months, and can provide them in electronic format, yourcosts may be reduced. You can ask your provider to email them to us atdentalrad@touro.edu or bring them with you on disk or flash drive to yourfirst appointment.Follow-Up CareAt the end of the appointment, we will assign you to a dental team thatis most suited to serve your dental needs and you will be given a followup appointment. At that appointment, you will have a comprehensiveevaluation and discuss the details and fees of a treatment plan that arespecific for you. The care that is provided by dental students will be closelysupervised by experienced dental faculty to ensure that you receive thehighest quality care.Emergency TreatmentFor new patients with a dental emergency including, but not limited to,broken restoration/fillings, bleeding, swelling, oral infection, and or/trauma,urgent care will be provided during normal business hours with noappointment necessary.Emergency treatment is available on a first come, first served basis, Mondaythrough Thursday, 8:00am – 4:00pm and on Friday from 8:00am – 1:00pm.The emergency evaluation fee is 75.00 plus additional fees for necessaryradiographs and treatment.For patients of record, after-hour emergencies are handled by the doctoron call. If you have an emergency, please call our main number at 914-5942700 and follow the recorded directions to reach our answering service.The answering service will locate the doctor on call and he/she will contactyou as soon as possible to assess your emergency care needs. If you thinkyou have a life-threatening emergency, please call 911 or go to the nearesthospital emergency center.Complex Care ClinicTouro Dental Health’s faculty-led Complex Care Clinic is available tomeet the needs of patients requiring more advanced dental treatmentand expertise under one roof. The clinic brings together TCDM facultyfrom multiple dental specialties who use the latest tools and techniquesin digital dentistry to efficiently educate and manage patients requiringcomplex dental restorations and implants. This team of experienced oralhealth professionals work together using on-site digital technologies tosave patients significant time while offering the affordable rates of aneducational institution.6

Online Bill PayTouro Dental Health offers a secure online payment system for patientsto pay their dental bills. To save time and limit person-to-person contact,we ask all patients to pay their balances in advance. Please allow 24 hoursfor payments to be applied to your account. For questions regarding yourbalance, please call 914-594-2700 (option 4) or visit or website to make apayment: dentalhealth.touro.eduQuestions or ConcernsPatients have the right to express concerns or complaints without fear ofreprisal and with the assurance that the presentation of a complaint willnot compromise the quality of their care or future access to care.Patients who have concerns about any aspect of the dental care or treatmentthey have received at the Touro Dental Health should discuss their concernswith the supervisor of the program where dental care was rendered. Patientsmay also register that concern either in person, by telephone, or in writing tothe Touro Dental Health Office of Clinical Operations.Director of Clinical OperationsTouro College of Dental MedicineTouro Dental Health19 Skyline Drive, Hawthorne, NY 10532914-594-27077

Patient ResponsibilitiesFinancial ResponsibilityYou are financially responsible for the treatment provided by Touro DentalHealth. You will receive a treatment plan with fees according to our currentfee schedule. Because of our focus on education, we are able to offer ourservices at affordable fees which are lower than the cost of comparableprocedures at most private practices.Your treatment and associated fees will be discussed with you priorto the start of the treatment. Payment is required at the time of yourappointment – we accept checks, cash, all major credit cards, New YorkState Medicaid Managed Care Dental Plans and most dental insurance.You will be responsible for any balance that might not be covered byyour insurance carrier.Dental InsuranceTouro Dental Health accepts cash, checks, all major credit cards, mostinsurance plans (subject to deductibles and co-payments, and certainguidelines) and New York State Medicaid Managed Care Dental Plans.It is each patient’s responsibility to know his/ her dental insurance benefits,please check with your employer or insurance plan with questions aboutcoverage.Dental Medical RecordsThe dental medical record, radiographic images, photographs, videos,models and other diagnostic aids relating to your treatment are theproperty of Touro Dental Health. You have the right to inspect suchmaterials and to request a copy of your dental medical records andradiographic images. A small fee is required for copying these items.You may request to receive any of your medical records or to send themto another health care provider by signing a Release of Information form.Touro Dental Health complies with requirements of the Health InsurancePortability and Accountability Act (HIPAA). You will receive separateinformation, forms and consents in that regard. In addition, your dentalmedical record may be used for instructional and educational purposes.Prescription DatabasesSome insurance companies, pharmacies, or other entities send informationon current and past patient prescriptions to electronic databases. TouroDental Health’s electronic record system may, from time to time, queryavailable prescription databases and receive such information concerningyour past prescriptions. These queries may not identify all your current andpast prescriptions. Therefore, it is important for you to keep an up-to-datelist and to provide this information to your provider.8

Keeping Your AppointmentsIt is important for you to be on time for your appointments. If you find thatyou are unable to keep an appointment, you must notify the student dentistor the patient coordinator for the practice at least 48 hours in advance,or 72 hours in advance of a surgical and/or sedation procedure.A total of three cancellations without 48-hour notice, or three missedappointments, or repeated unsuccessful attempts to arrange anappointment, may result in the discontinuance of further treatment.Patient Code of ConductYou have a responsibility to be considerate and respectful of the rights ofother patients and Touro Dental Health personnel and for respecting theproperty of other persons at Touro Dental Health. Indiscriminate use of obscene language, inappropriate behavior,or gestures while at Touro College of Dental Medicine may resultin dismissal. Patients who are under or perceived to be under the influence of alcoholor any other substance will not be treated at that time and can begrounds for dismissal. Inappropriate behavior or comments of a cultural, ethnic or sexualnature will not be tolerated and will result in you being discharged asa patient. Patients are not permitted to transfer from one student to anotherbased on race, creed, color, gender, national or ethnic origin, sexualpreference or disability.9

Patient’s Bill of RightsThe doctors and staff of Touro College of Dental Medicine recognize thatwhile you are a patient here you have the right, consistent with law, to:1. Understanding and use these rights. If for any reason you do notunderstand or you need help, we will provide assistance, including aninterpreter.2. Receive treatment without discrimination as to race, color, religion, sex,national origin, disability, sexual orientation, gender identity, source ofpayment or age.3. Receive considerate and respectful care in a clean and safe environmentfree of unnecessary restraints.4. Receive emergency care if needed.5. Be informed of the name and position of the persons who will be incharge of your care and names and position of administrative staff andrefuse their treatment, examination on or observation.6. Receive complete information about your dental diagnosis, treatment,and prognosis.7. Receive all the information that you need to give informed consentincluding possible risks and benefits for any proposed procedure ortreatment.8. Refuse treatment and be told what effect this may have on your health.9. Refuse to take part in research. In deciding whether or not toparticipate, you have the right to a full explanation.10. Privacy and confidentiality of all information and records regardingyour care.11. Participate in all decisions regarding your treatment.12. Review your dental record without charge. Obtain a copy of your dentalrecord for which we can charge a reasonable fee. You cannot be denieda copy solely because you cannot afford to pay.13. Receive an itemized bill and explanation of all charges.14. Complain without fear of reprisals about the care and services you arereceiving and have the provider respond to you, and if you request it,a written response. If you are not satisfied with the response, you cancomplain your concerns to the Faculty or to the Director of ClinicalOperations at 914-594-2707 and if you are still not satisfied, you maycontact the New York State Health Department and you will be providedtheir telephone number.10

Consents and PoliciesBelow, are copies of the consents and policies that you will be asked tosign electronically. Please review the information carefully and keep thisinformation for your records.Patient GuideI acknowledge that I was provided with a copy of the Guide to PatientServices.I have read, understand, and agree to abide by the aforementionedappointment policy and payment policy. I acknowledge that I wasprovided with a copy of the Touro Dental Health Notice of PrivacyPractices. I acknowledge that I reviewed and understand the consent todental treatment You will be asked to provide an electronic signature inacknowledgment of the above.Patients Who Are MinorsA parent or legal guardian must accompany patients who are minors atevery visit. This accompanying adult is responsible for payment of theaccount or must provide complete and accurate information about theguarantor on the insurance that will be billed.Appointment PolicyWe take great pride in the quality of care that we deliver. In an effort tomaintain this high-level of care, we have instituted appointment guidelinesregarding cancellation/no-show/lateness. Compliance with this policy willallow patients to receive treatment in a timely and efficient manner, promotingoptimal care and oral health.1. Once appointments are scheduled, patients are expected to attend eachand every session at the appointed time.2. If you are going to be more than 15 minutes late for your scheduledappointment, please call to let us know so that we may notify yourdoctor.3. All cancellations must be communicated to the department 48 hours inadvance or 72 hours in advance of a surgical and/or sedation procedure.4. If you cancel without proper notice or fail to show for 3 visits,you may be discharged from being provided care at the college.5. The College reserves the right not to reschedule patients who have beendischarged for failing to show for prior scheduled appointments.11

Touro Dental Health reserves the right to discontinue dental treatmentat its sole discretion. Should treatment be terminated, any remainingcredit balance for services not yet provided will be refunded. If you havea complaint that cannot be resolved at the student or faculty level, pleasecontact the Director of Clinical Operations at 914-594-2707.We appreciate your understanding and cooperation with this policy.I have read, understand and agree to abide by the aforementioned policy.Prescription DatabasesSome insurance companies, pharmacies, or other entities send informationon current and past patient prescriptions to electronic databases. TouroDental Health’s electronic record system may, from time to time, queryavailable prescription databases and receive such information concerningyour past prescriptions. These queries may not identify all your current andpast prescriptions. Therefore, it is important for you to keep an up-to-date listand to provide this information to your provider. By signing the consent, yougive Touro Dental Health Permission to access these electronic data bases.Authorization for Release of InformationI hereby authorize and consent Touro College of Dental Medicine to releaseto government agencies, insurance carriers, or others who are financiallyliable for the dental care, all information needed to substantiate paymentfor such care, and permits others who are representatives thereof toexamine and make copies of all records relating to such care and treatment.However, after disclosure has been made, it cannot be revoked retroactivelyto cover information released prior to revocation.Photo and VideoTouro Dental Health will take or use existing photographs, audio and /or video recordings, x-rays, film, movies, or other images or recordings ofpatients for education and training, student portfolios, students researchand presentations, etc.Assignment of BenefitsI hereby assign and set over to the above named Touro College of DentalMedicine, Inc. sufficient monies and/or benefits to which I may be entitledfrom government agency insurance carrier or others who are financiallyliable for my dental, medical care to cover the costs of the care andtreatment rendered to myself or my dependent in said practice. I understandthat I am responsible for charges not covered by my insurance plan.12

Email/Text Message CommunicationsAs a patient, you agree that we may communicate with you by electronicmeans such as (but not limited to) email or text message. We will makeevery attempt to Communicate over the Internet using a secure (encrypted)email/text messaging system. However, you must assume that there is noassurance of confidentiality when communicating via email /text messages.Touro Dental Health will not communicate health information that isspecially protected under state and federal law (e.g., HIV/AIDS, substanceabuse, mental health information) via email/texts.13

Please Read This Information CarefullyEmail communications are a two-way communication. However, responsesand replies to emails sent to or received by either you or your health careprovider may be hours or days apart. This means that there could be a delayin receiving treatment for an acute condition.Email messages on your computer, laptop, or other device have inherentprivacy risks especially when your email access is provided throughyour employer or when access to your email messages is not passwordprotected.Email is sent at the touch of a button. Once sent, an email message cannotbe recalled or cancelled. Errors in transmission, regardless of the sender’scaution, can occur. You can also help minimize this risk by using only theemail address that you provide to our practice / program / provider.In order to forward or to process and respond to your email, individualsat Touro Dental Health other than your health care provider may readyour email message. Your email message is not a private communicationbetween you and your treating provider. Neither you nor the person readingyour email can see the facial expressions or gestures or hear the voice ofthe sender. Email can be misinterpreted.At your health care provider’s discretion, your email message and anyand all responses to them may become part of your medical record.14

I understand and agree to the following: I certify the email address provided on this request is accurate, and thatI accept full responsibility for messages sent to or from this address. I have received a copy of the IMPORTANT INFORMATION ABOUTPATIENT EMAIL form, and I have read and understand it. I understand and acknowledge that communications over the Internetand/or using the email system may not be encrypted and may not besecure; that there is no assurance of confidentiality of information whencommunicated via email. I understand that all email communications may be forwarded to otherproviders for purposes of providing treatment to me. I agree to hold Touro Dental Health and individuals associated with itharmless from any and all claims and liabilities arising from or relatedto this request to communicate via email.If you have an urgent or an emergency, you should not rely solely onprovider / patient email to request assistance or to describe the urgent oremergency. Instead, you should act as though provider / patient email is notavailable 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 Ihave read and understand these consent forms, and that I have been giventhe opportunity to ask questions, I might have, and that all my questionshave been answered in a satisfactory manner.15

Notice of Privacy PracticesThis notice describes how medical information about you may beused and disclosed and how you can get access to this information.Please review it carefully.Your RightsYou have the right to: Get a copy of your paper or electronic medical record Correct your paper or electronic medical record Request confidential communication Ask us to limit the information we share Get a list of those with whom we’ve shared your information Get a copy of this privacy notice Choose someone to act for you File a complaint if you believe your privacy rights have been violatedYour ChoicesYou have some choices in the way that we use and share information as we: Tell family and friends about your condition Provide disaster relief Include you in a hospital directory Provide mental health care Market our services and sell your information Raise fundsOur Uses and DisclosuresWe may use and share your information as we: Treat you Run our organization Bill for your services Help with public health and safety issues Do research Comply with the law Respond to organ and tissue donation requests Work with a medical examiner or funeral director Address workers’ compensation, law enforcement, and othergovernment requests Respond to lawsuits and legal actionsA complete copy of this notice is available upon request, in our office, andon our web site.16

CONNECT WITH US!Please connect with us online for news,events and health information. Share yourstories and reviews so we can continue toimprove services for our patients and helpothers find affordable dental alinstagram.com/tourodentaldental.touro.edu/google

TOURO DENTAL HEALTHPHONE: 914.594.2700EMAIL: dentalhealth@touro.eduCLINIC HOURS OF OPERATION:8:00am – 5:00pm Monday through Thursday8:00am – 2:00pm FridayCALL CENTER HOURS:7:30am – 6:00pm Monday through Thursday7:30am – 3:00pm FridayLOCATION:19 Skyline Drive, 3rd FloorHawthorne, NY 10532DENTALHEALTH.TOURO.EDUREVISED FEBRUARY 2021

Touro Dental Health is located at 19 Skyline Drive in Hawthorne, NY. For detailed directions, visit: dentalhealth.touro.edu. DIRECTIONS BY CAR . Touro Dental Health is easily accessible from the Sprain Brook Parkway and I-287. Our facility is located within a New York Medical College building in the Skyline Drive office park.