Current Patients

We encourage you to learn about your privacy at UB Dental.

1. Understand and use these rights. If, for any reason, you do not understand or need help, the school will provide assistance;
2. Be treated and receive services with dignity and respect, regardless of race, religion, age, disability, gender, beliefs, marital status, lifestyle, sexual orientation, national origin or sponsor;
3. Be informed of the services available at the clinic;
4. Be informed of the provisions for off-hours emergency coverage;
5. Receive treatment in a clean and safe environment, free of unnecessary restraints;
6. Receive emergency, incremental and total care to completion consistent with the standard of care in the profession;
7. Be informed of and receive an estimate of the charges for planned services, view a list of the health plans and the hospitals that the center participates with; eligibility for third-party reimbursements and, when applicable, the availability of free or reduced cost care;
8. Receive an itemized bill, explanation of all charges or statement of account, upon request;
9. Receive an estimate of the amount that you will be billed after services are rendered;
10. Obtain from your health care practitioner, or the health care practitioner’s delegate, complete and current information about the diagnosis, treatment and prognosis in terms you can reasonably be expected to understand;
11. Assistance with non-English-speaking interpreter services;
12. Receive education, counseling and explanations to your questions;
13. Know the names, positions and functions of any personnel involved with your care;
14. Participate in all decisions about your treatment;
15. Receive the information necessary to give informed consent prior to the start of any non-emergency procedure or treatment, or both. An informed consent shall include, as a minimum, the provision of information concerning the specific treatment or procedure, the alternatives to care, the risk of no treatment, the reasonably foreseeable risks and benefits of the treatment and expected outcomes disclosed in a manner permitting you to make a knowledgeable decision;
16. Refuse examination or treatment to the extent permitted by law and be fully informed of the medical consequences to your action;
17. Refuse to take part in experimental research. In deciding whether or not to participate, you have the right to a full explanation;
18. Access to a patient advocate;
19. Voice grievances and recommend changes in policies and services to the University at Buffalo School of Dental Medicine staff, the operator and the New York State Department of Health without fear of reprisal;
20. Express complaints about the care and services provided and have University at Buffalo School of Dental Medicine staff investigate such complaints. The University at Buffalo School of Dental Medicine is responsible for providing a written response within 30 days, if requested, indicating the findings of the investigation. If you are not satisfied, you may complain to the New York State Department of Health;
21. Privacy and confidentially of all information and records pertaining to your treatment;
22. Approve or refuse the release or disclosure of the contents of your medical record to any health care practitioner and or health care facility except as required by law or third-party payment contract;
23. Access to your medical record per Section 18 of the Public Health Law, and Subpart 50-3. For additional information link to: Access to Your Medical Records and Do I Have the Right to See My Medical Records?
24. Review your records with a clinician and obtain a copy of your record for which the School of Dental Medicine can charge a reasonable fee;
25. Designate family members and other adults as authorized representatives to disclose protected health information, upon written authorization. You have the right to impose limits on the disclosures and revoke the authorization at any time, as permitted by law according to the Notice of Privacy Practices;
26. When applicable, make known your wishes in regard to anatomical gifts. Persons sixteen years of age or older may document their consent to donate their organs, eyes and/or tissues upon their death by enrolling in the NYS Donate Life Registry or by documenting their authorization for organ and/or tissue donation in writing in a number of ways (such as health care proxy, will, donor card, or other signed paper). 

REV. 1-12-2024; APPR. CC 4-29-2024

You have a responsibility to:

1. Provide, to the best of your knowledge, accurate and complete information about present medical and dental history, past illnesses, hospitalizations, medications, and other matters relating to your health.  You have the responsibility to report changes in your health status;
2. Follow the treatment plan agreed upon by you and your dental care providers. This may include following instructions of allied dental health personnel as they carry out the coordinated plan;
3. Make known to your dental care provider that you understand and agree to the treatment plan, and that you know what is expected of you;
4. Comply with the rules and regulations of the UB School of Dental Medicine, The State University of New York at Buffalo, and the State of New York;
5. Be on time and available for your appointments (3-4 times per month);
6. Have a working phone number in order for your dental provider to be able to contact you to schedule appointments;
7. Be considerate and respectful of the rights of other patients and UB School of Dental Medicine personnel.  You are responsible for being respectful of the property of other persons and the University at Buffalo. Patients are expected to treat UB faculty, students and staff with courtesy and respect. Inappropriate behavior or comments of a racial, cultural, ethnic or sexual nature will not be tolerated and may result in dismissal as a patient from the School of Dental Medicine;
8. Provide proper childcare while you are being treated at the SDM clinics. Children are not to be left unattended and are not permitted to accompany an adult patient who is receiving treatment;
9. Be escorted into patient treatment areas by your student dentist. No other individual should accompany you into the treatment areas unless medically necessary or approved by the student dentist’s faculty;
10. Pay for service at the time it is provided.                                                          

REV. 1-12-2024; APPR. CC 4-29-2024

The dental care you will be receiving is being provided by student dentists. These student dentists are in the process of completing necessary academic as well as clinical requirements to obtain a Doctor of Dental Surgery (DDS) degree. If, for any reason, you have a concern or comment regarding the treatment that is being provided, always consult with your student dentist and supervising instructor first. If satisfaction is not received you have the right to access our Patient Advocate.

The UB School of Dental Medicine’s Patient Advocate can be reached:

• By phone: 716-829-2390
• By mail: UB School of Dental Medicine, 325 Squire Hall, Buffalo, NY 14214-8006

Hours are by appointment. You may also contact the New York State Department of Health’s Office of Health Systems Management.

The University at Buffalo School of Dental Medicine (“UBSDM”) offers optional electronic communication for patients. Electronic communications from the UBSDM may include the Patient Portal, email or text messages. Electronic communication can be a useful tool for your dental care, however, it is important that you understand the risks of this form of communication as well as your responsibilities if you decide to participate in this service. By allowing electronic communications with the UBSDM, you are agreeing to comply with and be bound by the following terms of use. Please review the following terms carefully. If you do not agree to these terms, you should not allow electronic communication with the UBSDM.

General Terms

Accuracy and Integrity of Information
Although the UBSDM attempts to ensure the integrity of all electronic communications, it makes no guarantees whatsoever as to the correctness or accuracy of the information contained therein. It is possible that electronic communications could include typographical errors, inaccuracies or other errors. In the event that an inaccuracy arises, please inform the UBSDM so that it can be corrected. Information disseminated via electronic communication may be changed or updated without notice.

Risks and Limitations of Electronic Communication
The UBSDM will use reasonable means to protect the security and confidentiality of information transmitted via electronic communication, however, it is important that you are aware of the inherent risks and limitations of this form of communication. Electronic communications present the risks of breach of privacy or confidentiality, difficulty validating the identity of parties and potential delays in response. Electronic communications may be misdirected, which increases the risk of receipt by unintended or unknown recipients. Back-up copies may be stored on a computer system even after the sender or recipient have deleted copies of electronic communications.  Electronic communications may also inadvertently introduce malware into a computer system, which could damage or disrupt the computer, network or security settings. Some forms of electronic communications, such as text messaging, may incur additional fees or charges with your cell phone carrier.

Minor Eligibility
An individual must be age 18 or older to agree to electronic communications with the UBSDM. Parents or legal guardians of minor patients may request to receive electronic communications regarding the minor patient.

Proxy Access to Electronic Communications
UBSDM patients age 18 or older who have medical decision-making capacity may request that electronic communications be provided to another adult individual (“proxy”) by completing the UBSDM Authorized Representative Form and submitting it to the UBSDM.

Legally authorized decision-makers of adult patients who lack medical decision-making capacity may request electronic communications by completing the UBSDM Authorized Representative Form and submitting it to the UBSDM.

The UBSDM reserve the right to revoke proxy access at any time for any reason.

Opting Out
Electronic communications are an optional service the UBSDM provides to patients. You may withdraw your consent to participate in electronic communications at any time. Please contact the UBSDM at 716-262-9750 to opt out of electronic communications.

Governing Law
This Agreement shall be governed by New York law notwithstanding any conflicts of law provisions to the contrary.

Terms for Communications Involving Protected Health Information

Dental/Medical Advice Disclaimer
Never use electronic communications for a medical or dental emergency or urgent health issue. Contact emergency personnel if you need immediate help with a medical emergency. Please review the UBSDM’s Emergency Care webpage for information about seeing care for dental emergencies at the UBSDM.

Privacy of Your Health Care Information
The privacy of patients’ protected health information (“PHI”) is protected by state and federal laws including the Health Insurance Portability and Accountability Act (“HIPAA”). If you have questions or wish to learn more about the privacy and security of your protected health information at UBSDM, view the Notice of Patient Privacy. Please note that an Authorization for Release of Health Information form must be completed if you request that your health information is sent to another individual that is not a licensed healthcare provider directly involved in your care.

Terms for Communications Not Involving Protected Health Information

Copyright
The content, organization, graphics, design, compilation, magnetic translation, digital conversion and other matters related to electronic communications from the UBSDM are protected under applicable copyrights, trademarks and other proprietary (including but not limited to intellectual property) rights. The copying, redistribution, use or publication by you of any such matters or any part of UBSDM electronic communications, except as otherwise permitted by this document, is strictly prohibited. You do not acquire ownership rights to any content, document or other materials viewed or transmitted through the UBSDM’s electronic communications. The electronic transmission of information or materials does not constitute a waiver of any right in such information and materials. Some of the content transmitted via electronic communications is the copyrighted work of third parties.

Limited License; Permitted Uses
You are granted a non-exclusive, non-transferable, revocable license (a) to access and use electronic communication methods offered by the UBSDM strictly in accordance with this Agreement; (b) to participate in electronic communication methods offered by the UBSDM solely for internal, personal, non-commercial purposes; and (c) to reproduce discrete information transmitted by electronic communications solely for internal, personal, non-commercial purposes and provided that you maintain all copyright and other policies contained therein. No print out or electronic version of any part of the UBSDM’s electronic communications or their contents may be used by you in any litigation or arbitration matter whatsoever under any circumstances.

Restrictions and Prohibitions on Use
Your license for participation with UBSDM electronic communications and any information, materials or documents (collectively defined as “Content and Materials”) therein are subject to the following restrictions and prohibitions on use: You may not (a) copy, print (except for the express limited purpose permitted by the “Limited License; Permitted Uses” section above), republish, display, distribute, transmit, sell, rent, lease, loan or otherwise make available in any form or by any means all or any portion of the UBSDM electronic communications or any Content and Materials retrieved therefrom; (b) use any materials obtained via the UBSDM electronic communications to develop, of as a component of, any information, storage and retrieval system, database, information base, or similar resource (in any media now existing or hereafter developed), that is offered for commercial distribution of any kind, including through sale, license, lease, rental, subscription, or any other commercial distribution mechanism.

Information Does Not Constitute Dental/Medical Advice
The UBSDM assumes no responsibility for how you use the information you obtain from the UBSDM via electronic communications. You should consult with your dental care provider regarding your own condition and how the content of electronic communications from the UBSDM may or may not apply to you. Electronic communications are not a substitute for appropriate and timely contact with your health care provider. You should never change or stop any course of treatment prescribed by your health care provider without first consulting him or her.

Acceptance of Agreement

By opting in to electronic communications with the UBSDM, you agree to the terms and conditions outlined in this Terms of Use Agreement for Electronic Communications ("Agreement"). This Agreement constitutes the entire and only agreement between us and you, and supersedes all prior or contemporaneous agreements, representations, warranties and understandings with respect to electronic communications, the content, products or services provided by or through electronic communications, and the subject matter of this Agreement, except for any Authorizations for Release of Health Information that are currently on file or any Authorizations for Release of Health Information that may be executed in the future Authorizations for Release of Health Information are available on the UBSDM website and on the Patient Portal.

This Agreement may be amended at any time by us from time to time without specific notice to you. The latest Agreement will be posted to the UBSDM website, and you should review this Agreement prior to agreeing to electronic communications. The UBSDM does not guarantee the availability, or content completeness or accuracy of its electronic communications. The UBSDM reserves the right to discontinue electronic communications at any time for any reason.

Version 1.0 – 09.17.2024 KVL