New Patient Form

NOTICE OF PRIVACY PRACTICES

Practice Name: Lovejoy Dental

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Effective Date: 1/26/2026

This Notice of Privacy Practices ("Notice") applies to the healthcare services provided by this practice (the "Practice"). The Practice is required by law to maintain the privacy of your protected health information (PHI), provide you with this Notice, and follow the terms of the Notice currently in effect.

1. OUR DUTIES

We are required by law to:

• Maintain the privacy and security of your PHI
• Provide you with this Notice of our legal duties and privacy practices
• Notify you following a breach of unsecured PHI
• Abide by the terms of this Notice

2. HOW WE MAY USE AND DISCLOSE YOUR PHI

A. Treatment, Payment, and Health Care Operations

We may use and disclose your PHI without your authorization for the following purposes:

• Treatment: To provide, coordinate, or manage your health care. This may include sharing information with physicians, dentists, specialists, laboratories, pharmacies, or other health care providers involved in your care.
• Payment: To bill and collect payment for services, determine insurance coverage, obtain prior authorizations, and respond to payer requests.
• Health Care Operations: To support business functions such as quality improvement, peer review, credentialing, training of staff and students, licensing, accreditation, audits, legal services, and general administrative activities.

B. Business Associates

We may disclose your PHI to business associates that perform services on our behalf, such as billing companies, IT vendors, cloud service providers, shredding services, and legal or accounting firms. Business associates are required by law to protect your PHI and may use or disclose it only as permitted by their contract with us and by law.

C. Individuals Involved in Your Care

We may disclose PHI to a family member, friend, or other person involved in your care or payment for your care, unless you object or we determine it is not in your best interest to do so.

D. Other Permitted or Required Uses and Disclosures

We may use or disclose PHI as required or permitted by law for public health activities, reporting abuse or neglect, health oversight activities, judicial or administrative proceedings, law enforcement purposes, workers' compensation, and to avert a serious threat to health or safety.

3. REPRODUCTIVE HEALTH INFORMATION

We will not use or disclose PHI for the purpose of investigating or imposing liability related to lawful reproductive health care, including abortion, miscarriage, contraception, or fertility services, as prohibited by federal law.

We will not disclose reproductive health information to law enforcement or other parties without a valid attestation or authorization when required by law.

4. SUBSTANCE USE DISORDER (SUD) RECORDS

If applicable, records related to substance use disorder treatment that are protected under 42 CFR Part 2 will be used or disclosed only as permitted by federal law.

If this Practice does not provide SUD diagnosis or treatment, references to substance use documented in your medical record are treated as HIPAA-protected PHI and are not Part 2 records.

5. MARKETING

We will not use or disclose your PHI for marketing purposes without your written authorization, except as permitted by law. If authorization is required, you may revoke it at any time in writing.

6. FUNDRAISING

We may use certain limited information (such as your name, address, phone number, and dates of service) to contact you for fundraising purposes. You have the right to opt out of receiving fundraising communications at any time. Your decision to opt out will not affect your treatment or payment for services.

Each fundraising communication will include a clear and simple method for opting out.

7. YOUR RIGHTS

You have the right to:

• Inspect and obtain a copy of your medical or dental records, including electronic records, subject to limited exceptions
• Request an amendment to your PHI if you believe it is incorrect or incomplete
• Request restrictions on certain uses or disclosures of your PHI (we are not required to agree to all requests)
• Request confidential communications, such as receiving information at an alternative address or by alternative means
• Receive an accounting of disclosures of your PHI as required by law
• Receive a paper copy of this Notice, even if you have agreed to receive it electronically
• Access your information electronically through patient portals or other secure systems, when available
• File a complaint if you believe your privacy rights have been violated, without fear of retaliation

8. BREACH NOTIFICATION

You will be notified if a breach occurs that compromises the privacy or security of your PHI.

9. STATE-SPECIFIC RIGHTS

Oregon

Under Oregon law, patients may have additional rights related to:

• Access to medical records
• Reproductive health privacy protections
• Restrictions on disclosure of sensitive health information.

10. CHANGES TO THIS NOTICE

We reserve the right to change this Notice and make the revised Notice effective for PHI we already maintain. The current Notice will be available upon request and posted in our office.

11. CONTACT INFORMATION

Practice Name: Lovejoy Dental
Privacy Officer or Contact Person: Dr Matthew Young and Dr Tyler Way
Phone: 503-889-8632
Email: contact@lovejoy-dental.com
Address: 930 NW 14th Ave., Ste. #220, Portland, OR 97209

You may also file a complaint with:

U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
1-877-696-6775

LOVEJOY DENTAL PATIENT FINANCIAL AGREEMENT
We stand strong in our commitment to help our patients achieve ultimate oral health.
We offer the following agreement and payment options.

**ALL ESTIMATED FEES ARE DUE AT THE TIME OF SERVICE**

FOR OUR PATIENTS WITH DENTAL INSURANCE:
We will gladly verify your dental benefits and process your primary and secondary insurance claims with the following agreement:

• Your dental insurance is an agreement between you and your insurance company.
• All patient copayments and/or patient portions are only an estimate/never a guarantee of payment.
• As part of your contact with your insurance company, you are responsible for all out of pocket portions/copayments and deductibles.
• Insurance payments not paid after 90 days will become your complete responsibility and must be paid in full.

PAYMENT OPTIONS:

• For your convenience, we accept Visa, MasterCard, Check, Money Order or Cash (exact change please)
• Care Credit, specializing in helping patients finance larger dental or orthodontic cases. No down payment is required, and payments can be made up to 12-18 months with no interest rates.

MISSED APPOINTMENTS OR SHORT NOTICE CANCELLATIONS:
We understand that your plans and daily schedule can change. When they do, a 24 hr notice is greatly appreciated when you need to reschedule your appointment. A fee of $25.00 will be assessed to cancelations with less than 24 hrs notice and a fee of $50.00 will be assessed with no notice prior to appointment.

GUARANTEE OF WORK:
Lovejoy Dental guarantees its dental work for 24 months after the service has been completed, provided you have maintained 2 regularly scheduled preventive appointments annually.

I have read, understand and agree to all of the above. I have been given the opportunity to ask questions. If I have insurance, I hereby authorize my insurance company to pay my dental benefits directly to the doctor. I authorize Lovejoy Dental to release any of medical information to my insurance company as needed to process my insurance claim.
**FORM WILL BE SIGNED ELECTRONICALLY AT THE FRONT DESK**