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Financial Enrollment Agreement

TMIKY, Choice MD, IDTKY Financial Enrollment Agreement

CAMPUS INFORMATION:

Admission Representative:

COURSE INFORMATION:

Program Name:

STUDENT INFORMATION:

Full Name:

PAYMENT INFORMATION:

Method of Payment:

Program Cost:

Canvas Start Date & First Day of Attendance:

Skills Start Date:

End Date:

SCHOLARSHIP:

Scholarship Type: Institutional Scholarship

Scholarship Amount: $

By initialing below you are accepting the scholarship(s) awarded and understand any and all scholarships provided by TMIKY - Choice MD - IDTKY are based off of individual qualifications at the time of application and are between the recipient and said institution.

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By initialing below you are acknowledging you have read the and understand this agreement and acknowledge receipt of a copy. You understand the awarded scholarship cannot be transferred to another institution or person and some may only apply to certain offered programs. You are also required to maintain full time enrollment and minimal academic standards per the student catalog. You understand that if you default upon this agreement, the awarded scholarship will be revoked and you will be responsible for any and all fees set by any and all financial lenders.

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Please read this Enrollment Agreement thoroughly as you are agreeing to the following:

STUDENT PROTECTION FUND

KRS 165A.450 requires each school licensed by the Kentucky Commission on Proprietary to contribute to a Student Protection Fund which will be used to pay off debt incurred due to the closing of a school, discontinuance of a program, loss of license, or loss of accreditation by a school or program.

PROCESS FOR FILING A CLAIM AGAINST THE STUDENT PROTECTION FUND

To file a claim against the Student Protection Fund, each person filing must submit a completed "Form for Claims Against the Student Protection Fund". This form can be found on the website at www.kcpe.ky.gov

MEDIA POLICY:

I, Undersigned, do hereby give my consent and agree the TMIKY - Choice MD - IDTKY employees have the right to take photographs, videotape, or digital recordings of me to use in any and all media outlets. I further consent that my name and identity may be revealed therein or by descriptive text or commentary. I understand there will be no financial or other forms of remuneration for any of the above, either for initial or subsequent transmission or playback. I represent I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement.

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OSHA STANDARDS:

To be in compliance with OSHA standards on bloodborne pathogens, each student must be informed of the mandatory Universal Precautions in all healthcare settings. These standards and precautions are included and covered in detail within the courses. This must be completed by the student prior to externship eligibility. It is also required that students be informed and encouraged to begin the Hepatitis B vaccine series. However, you may decline vaccination at this time. Students are required to read and sign the Hepatitis B Statement of Informed Consent prior to placement in an externship facility. Students will be required to meet all OSHA requirements on the externship. In addition, each individual facility may have some variation of these rules and regulations and it is the student’s responsibility to obtain a copy of these rules and regulations at that externship site. Those regulations set forth by that facility, must also be met by the student.

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STUDENT EXPOSURE INFORMATION:

TMIKY - Choice MD - IDTKY students are responsible for:

Reading this student information sheet and following the guidelines.
Identifying the appropriate contacts on campus and at externship sites.
Paying for all expenses either through their own health insurance or other personal means associated with testing, medications, and related costs.
Providing medical expenses to include blood work requested of source patients.

If you experienced a needle stick or sharps injury or were exposed to the blood or other body fluid of a patient/student during the course of your extern/study, immediately follow these steps:

Wash needle sticks and cuts with soap and water
Flush splashes to the nose, mouth, or skin with water
Irrigate eyes with clean water or saline
Report the incident to your instructor
Refer to exposure control plan and fill out exposure report form
Students should have appropriate initial laboratory tests if needed per current CDC guidelines performed as soon as they can get and appointment but no later than the next business day

Students are not an employee of the school ; therefore, they are not eligible for worker’s compensation benefits (although they may be required to complete similar paperwork to document the details of the exposure). The student will be responsible for the cost of their care, either through their own health insurance or other personal means. All source patients are encouraged to have blood work as designated by the CDC protocol current at the present time (presently HCV antibody, HIV antibody, and Hepatitis B surface antigen). The student requesting the blood work may be held responsible for the cost of treatment for the source patient.

Students will be directed to have source patient information available for their discussion with the appropriate personnel at the outside facility, if available, concerning the exposure:

Approximate time of exposure
Location of exposure (e.g., school, medical or dental office, etc.)
Source of the exposure (e.g., blood, contaminated instrument, etc.)
Type of exposure (e.g., skin, mucous membrane percutaneous)
Length of exposure (e.g., seconds/minutes/hours)
Status of the source patient: Negative, Positive, or Unknown HIV, HBV, and HCV status
Whether or not patient is at risk for HIV,HBV, or HCV infection because of:
- Multiple blood transfusions 1978-1985
- IV drug user
- Multiple hetro- or homosexual partners
- Known HIV positive and/or have symptoms of AIDS, HBV or HCV
- Significant blood or bodily fluid exposure has occurred

TMIKY - Choice MD - IDTKY will not be held responsible nor pay expenses incurred from student exposure, to include needle sticks. TMIKY - Choice MD - IDTKY recommend students seek medical treatment if necessary and to follow the treatment protocol advised from the medical facility at the expense of the student. Students assume their responsibility upon enrollment as there are risks associated with study and employment in the healthcare field.

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STUDENT EXTERNSHIP/OBSERVATION CONFIDENTIALITY AGREEMENT

I will keep all patient information confidential. I will disclose patient information in accordance with the policies of the facility that I am assigned to during my student externship experience. Furthermore, I understand and agree to comply with the guidelines set forth by HIPAA.

I will not discuss any information, patient-related or relating to the operations of the facility to include my own health record if applicable. I will keep all security codes and passwords used to access the facility, equipment and computer systems confidential.

I will access or view patient information only as it is required in the scope of my student experience to include my own health record if applicable.

I will not disclose, copy, transmit, modify or destroy patient information or other confidential practice information without the permission of my supervisor or the practice’s privacy officer.

I agree to comply with these conditions even after my student externship experience is terminated.

I understand violation of this agreement may result in disciplinary action, up to and including termination from the externship and dismissal from my program. My signature on this agreement indicates that I, a student of TMIKY - Choice MD - IDTKY have read, understand and will comply with all aspects of this confidentiality agreement.

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CPR CERTIFICATION:

TMIKY - Choice MD - IDTKY students are required to obtain "Healthcare Provider" CPR to begin externship/observation. Documentation is required to be presented prior to being placed at a facility. CPR courses may be available on campus or locally, it is the responsibility of the student to obtain CPR, not the schools. You may ask your instructor for further details.

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MISCONDUCT POLICY:

Students must adhere to conduct that will not interfere with the learning process of any other student, teacher,externship site, or the progress of the class in general. Those students whose conduct reflects discredit upon themselves or the school will be subject to immediate expulsion. The TMIKY - Choice MD - IDTKY reserves the right to exercise judgment of a student and to terminate a student for any of the following reasons:

Breach of the school enrollment agreement, Failure to abide by the rules and regulations of any clinical site, Entering school grounds or externship site while under the influence of any type of, Alcohol or drugs , Possession of a dangerous or deadly weapon concealed or otherwise, Instigation, or participation in, rebellious activities against the school or its students, Solicitation which reflects unfavorably upon the school or its students, Failure to conform to the rules and regulations of the school, Conduct that reflects unfavorably upon the school or its students, Excessive absences or tardiness at campus or externship, Failure to pay charges when due, Cheating, Falsifying school records, Written or verbal profanity on campus/externship grounds, Vandalism of campus property, Disruptive classroom behavior, Physical threats of any nature, or Theft of any kind.

First Offense:
Behavior- The student is issued a written warning. A copy is kept in student’s file.
Academic- The student must redo or modify the assignment or exam at a 30% penalty, if student refuses to redo a zero will be earned.
Second Offense:
Behavior- The student must meet with the Program or Campus Supervisor to determine a course of action. A plan of action and/or incident report will be placed in student’s file.
Academic- The student will receive a zero on the item in question. No redo’s allowed.
Third Offense:
Behavior or Academic- The student will be expelled. Written documentation will be placed in student’s file.
When a student is determined to be guilty of academic or behavioral misconduct, the instructor will determine if a prior offense exists. Offenses accumulate during the students’ academic program(s). If prior incidents have occurred they will impact the current offense. Misconduct incidents may merit immediate expulsion and no warnings will be given, dependent on severity and outcome. TMIKY - Choice MD - IDTKY strive to graduate only the upmost professional medical and dental assistants.

By signing this agreement you agree to having read and fully understand the expectations as a student at TMIKY - Choice MD - IDTKY regarding misconduct.

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DRESS CODE:

These guidelines are enforced to help maintain a professional environment and familiarize students to the professional attire required in the healthcare field.

Required uniform includes: solid colored royal blue scrub top and pants and watch with a second hand. Dental students white scrub jackets. Scrubs should fit properly (undergarments should not be visible) when standing, sitting, bending or stooping, if in doubt go up a size. NO SMART WATCHES. This is the same as having a cell phone on your wrist. Must be a regular watch with a second hand
Name tag and scrubs must be worn during observation/externship.
Footwear must be a closed toe athletic or nursing style shoe. No open toe shoes, loafers, flip flops, or UGG type shoes.
Jewelry should be limited to one ring per hand, a watch, and no more than 2 discreet (pierced) earrings per ear. No dangle or large hoop earrings. No visible facial/body piercings of any kind. Students who have stretched earlobes should wear “flesh” colored jewelry.
Hair is to be clean, short or pulled back during skills. Hair color should be within the natural color range (blondes, browns, blacks, grays). No large hair accessories or headgear (i.e. bandanas and scarves)
Sideburns, mustaches and/or beards are to be clean, short and neat.
Fingernails are to be short (active length- longer than fingertips) and clean. No colored nail polish or artificial nails. (Clear nail polish is acceptable)
Avoid using strong perfumes/colognes. Strong smelling lotions and powders may also be considered offensive or create an allergic reaction during patient interactions.
Personal hygiene should be considered: daily showers, deodorants, etc. No coffee breath, smoker’s breath, or smoke odors.
Make up should be modest. No false eyelashes, glittery or bright colors.
Visible piercings (other than allotted earrings are unacceptable. This includes tongue rings and large ear gauges.
If a student has a tattoo it must be covered by makeup or clothing. Please understand that due to the nature of public opinion, we cannot guarantee a facility will not discriminate due to visible tattoos or tattoos that cannot be covered (i.e. facial, neck, or hand tattoos)

NOTE: Students not meeting the Uniform/Dress Code and Personal Appearance standards will be directed to leave the campus until properly attired. This will count as an absence/tardy.

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DRUG POLICY:

TMIKY - Choice MD - IDTKY is committed to providing a safe and professional work environment for our students, volunteers, faculty and staff while on campus or at a clinical affiliation.

All students must be physically and mentally free of illegal drugs, alcohol, and prescription drugs that impair their intellectual and emotional functions. Some clinical affiliations (externships) require students to complete drug screening and/or a background check prior to clinical placement, or during if suspect of drug use. A positive drug screen may exclude you from clinical placement, graduation, and may warrant dismissal from the school.

Without exception, any student found in possession of these substances or a student is suspected of being under the influence of these substances (alcohol, illegal drugs, and prescription drugs) the Instructor and/or the Campus Supervisor will ask the student to leave the facility and immediately be drug tested at the student’s expense. Results are to be faxed directly to the instructor and must be received within 24 hours of being dismissed. The results will only be shared with the Instructor, Campus Supervisor and Education Director.

A positive test, failure or refusal to complete requested drug testing will result in automatic dismissal from the program. In the event of a positive test result, resources will be made available to the student to assist in counseling, treatment, or rehabilitation. Any student wishing to re-enroll after a positive drug screen or refusal to submit to testing must comply with an immediate drug screen upon admittance and is subject to random drug screening during their program at the student’s own expense. Any further positive test results or refusal will be cause for expulsion without option to re-enroll.

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TAX INFORMATION

TMIKY - Choice MD - IDTKY post-secondary educational establishments are NOT eligible for Title IV funding or Student Aid programs administered by the U.S. Department of Education. The federal government generally does not provide loans, grants or other forms of financial assistance to students attending a non-accredited college. (www.irs.gov)

According to the IRS, students can only deduct their loan interest if the loan was used at a school that participates in the U.S. student aid program. This is limited to schools with approved accreditation. Therefore, TMIKY - Choice MD - IDTKY schools are not eligible to provide tax Form 1098-T for tuition statement or Form 1098-E for student loan interest statement. Personal loans are utilized for educational purposes, and students are advised and must authorize this attestation in advance of attendance.

Tax preparers will be supplied a W-9 Form upon request. TMIKY - Choice MD - IDTKY employees are not qualified to advise students on tax matters.

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HEPATITIS B VACCINATION & TUBERCULOSIS INFORMED CONSENT

By signing the agreement you are agreeing to the following:am currently enrolled as a Dental or Medical student at The Medical Institute of Kentucky. I have been informed and understand that due to my possible exposure to blood and other potentially infectious substances, I may be at risk of acquiring TB, Hepatitis B, HIV infection or other infectious contagions.

I have been advised that vaccination for Hepatitis B is available through any local physician and is recommended by TMIKY - Choice MD - IDTKY and the instructors therein. I understand that Hepatitis B is a serious disease.

I (medical student) have been advised that I am required to obtain TB testing before I may begin the skills portion of my medical education. Dental students have been advised that the school also recommends TB testing before beginning the skills portion of the dental program.

I have been given the opportunity to ask questions about inoculation and risks involved in receiving the vaccines and in declining vaccination. My questions have been answered to my satisfaction. I understand that TMIKY - Choice MD - IDTKY is not responsible for my attaining vaccinations or liable in the event that I should contract any contagion during my education. I understand my externship site may request records before attendance, and I am responsible for obtaining them in a timely manner.

I have already been vaccinated or have started the Hep B series. I will supply proof of vaccination by first skills day.

I do not plan to receive the Hep B vaccination at this time; however, I understand I may receive the vaccination at a later date. I will in inform the admissions department if I receive or plan to receive the series.

I have already been TB tested (within 6 months) or plan to receive before the first week of class. I will supply proof by first skills day.

I (dental student) do not plan to obtain TB testing at this time, I understand I may obtain at a later date.

CANCELLATION & REFUND POLICY:

Student must provide written notice of cancellation/withdrawal either by electronic submission to http://tmiky.com/withdraw-request/ or by certified mail, to include: name, date, program enrolled, campus location and reason for cancellation to:

ATTN: Cassie Black, Operations Manager

2704 Old Rosebud Rd, Suite 130

Lexington, KY 40509

Program Cancellation:

The school may cancel a program at its discretion. Should this occur, any students enrolled prior to cancellation, will be notified of this change and will have the option of applying all monies paid toward another program or receiving a refund of all tuition paid within 60 days of the cancellation date.

Cancellation:

An applicant, who provides electronic submission or certified letter of cancellation after executing the enrollment agreement, but prior to the digital orientation of the program, is entitled to a full refund of all paid tuition. Unless they have been offered or secured employment in the field as a result of enrollment. Students have six months from enrollment date to seek any refunds of paid tuition. All refunds will be made within 60 days of the written notice receipt.

Withdrawal Procedure:

Students choosing to withdraw from a program after the digital orientation date are required to provide written notice of withdrawal as required above (attendance will be calculated until electronic submission or certified letter is received) and advised to meet with the On-site Administrator to complete an exit interview. The purpose of the exit interview is to assess the academic and financial status of the student.
The Medical Institute of Kentucky, Choice MD and IDT has selected three consecutive scheduled class absences, without prior administrative approval, as the unofficial date which a student is deemed to have withdrawn. Students have six months from the last attended date of class to request a refund of monies paid towards tuition. After this deadline, no refunds will be issued.
For students seeking a refund of tuition: Refunds are based on the amount of tuition paid, fees not included in tuition are non-refundable. Administrative fee of $200 will be deducted from the refund amount. Students who received tuition credit should assume the amount credited will be deducted from the refund amount. All refunds will be made within 60 days of the receipt of the certified letter or electronic submission. Refunds will be calculated as follows: Digital Orientation through Week 2- 75% refund, Week 3 through Week 4- 50% refund, Week 5 through Week 6- 25%, No refunds after Week 6. Students not eligible for refund will be offered the option to take a Leave of Absence (LOA) and return to complete the program within 30 days from withdrawal date.
Students who have acquired or been offered employment in the field upon enrollment are not eligible for tuition refund. Students who receive a refund will not be eligible to receive any certificates as all courses in the program must be completed to receive a certificate of completion. Students who receive a refund are not eligible for any future institutional scholarships.

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INFORMATION AUTHORIZATION

Complete this portion only if you want us to provide information about you to an individual or group. Print the name of those who you want information (academics and/or financial) to be released.

Name: Relationship:

CATALOG DELIVERY:

Upon execution of this agreement the TMIKY - Choice MD - IDTKY catalog, which contains information describing programs offered, will be electronically delivered to you on the date of this agreement. The date executed is .

STUDENT ACKNOWLEDGEMENTS:

I have carefully read and received an exact copy of this enrollment agreement. This is a legal binding document and there has been no verbal or written agreements or promises other than those appearing in this agreement.

By checking this you are agreeing to Attestation of a high school graduation or equivalent. You are agreeing to supply the necessary documents if assigned by TMIKY/ChoiceMD/IDTKY.

I understand that TMIKY/ChoiceMD/IDTKY may terminate my enrollment if I fail to comply with attendance, academic, and financial requirements or if I fail to abide by established standards of conduct, as outlined in the school catalog. While enrolled at TMIKY/ChoiceMD/IDTKY, I understand that I must maintain satisfactory academic progress as described in the school catalog and that my financial obligation to the school must be paid in full before a certificate will be awarded.

I understand that TMIKY/ChoiceMD/IDTKY does not guarantee job placement to graduates/students upon program completion or upon graduation.

I acknowledge that the date listed "First Day of Attendance" is correct.

I Have read and understand this agreement and acknowledge receipt of a copy. I understand that I default upon this agreement, I will be responsible for payment of any collection fees or attorney fees incurred by TMIKY/ChoiceMD/IDTKY.

PARENT/GUARDIAN STATEMENT:

If over the age of 18 years please move forward with the agreement.

Check if you are under the age of 18 and need Parent or Guardian approval for this agreement.

If checked please print the document after completion and have Parent or Guardian Sign below.

____________________________________________

Parent/Guardian Signature

Leave this empty:

Your legal name

Your email address

Timestamp

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August 19, 2022 2:16 pm EDT

Financial Enrollment Agreement Uploaded by Greg Goins - [email protected] IP 2603:6011:1d00:eb:b5a5:5d6e:f572:7928

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