Notice of Privacy Practices

Ordot Dental Clinic, LLP

THIS NOTICE DESCRIBES HOW YOUR DENTAL INFORMATION MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS INFORMATION CAREFULLY.

Effective February, 2026

Ordot Dental Clinic, LLP (“Ordot Dental”, “We”, or “Our”) uses health information about you for treatment, payment and health care operations. Your health information is contained in paper and electronic records that are the property of Ordot Dental.

This Notice applies to all Protected Health Information (“PHI”) created, received, maintained, or transmitted by Ordot Dental, whether in written, electronic or oral form. You have a right to obtain a paper or electronic copy of the Notice of Privacy Practices upon request and to discuss it with Dr. Andrew B. Eusebio at 671-477-8215 if you have any questions.

Your Health Information Rights

You have the right to:
• Inspect and obtain a copy of your dental records held by Ordot Dental upon request.
• Request a restriction on certain uses or disclosures of your protected health information, however, we are not required to agree to a requested restriction.
• Request to amend your dental records.
• Request communications of your dental information by alternative means or at alternative locations.
• Choose someone to act for you.
• Revoke your authorization to use or disclose dental information except to the extent that action has already been taken.
• Get a list of those with whom we’ve shared your information.
• File a complaint if you believe your privacy rights have been violated.

Your Rights (More Specifically Explained)

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 30 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, office, or cell 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,” for example, if it could affect your care. If we agree to your request, we may still share this information in the event that you need emergency treatment.
• 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 paper copy promptly.

Choose someone to act for you:
• If someone has authority to act as your personal representative, such as if someone has your 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 on page 1. (See below for more information).
• You will not be retaliated against 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 or payment for your care
• Share information in a disaster relief situation
• Include your information in a clinic directory
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

Use or Disclosure of Your Health Information

For Treatment:
We may use your health information to provide you with dental treatment and services. For example, information we obtain will be included in your dental records that is related to your treatment. This information is necessary for us to determine what treatment you should receive. We will also record actions taken in the course of your treatment and note how you respond to the actions.

For Payment:
We may use and disclose your health information to others for purposes of receiving payment for treatment and services that you receive. For example, we may send a claim to your insurance carrier, in order for your insurance carrier to make payment based upon your dental benefits coverage. The information on the claim will include information that identifies you, your diagnosis and treatment or supplies used in the course of treatment.

For Health Care Operations:
We may use and disclose health information about you for operational purposes, improve your care, run our practice, and contact you when necessary. For example, your dental information may be disclosed to your dental insurance carrier to:
• Evaluate the performance of your dentist or other professionals who are treating you;
• Assess the quality of care and outcomes in your cases and similar cases; and
• Learn how to improve our services to you.

Appointments:
We may use your information to provide appointment reminders or information about treatment alternatives or other dental-related benefits and services that may be of interest to you.

Required by Law:
We may use and disclose information about you as required by law. For example, we may disclose information for the following purposes:
• Respond to lawsuits and legal actions;
• For judicial and administrative proceedings pursuant to legal authority;
• To report information related to victims of abuse, neglect or domestic violence; and
• To assist law enforcement officials in their law enforcement duties.

Public Health:
Your health information may be used or disclosed for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury or disability, helping with product recalls, reporting adverse reactions to medications, or for other
health oversight activities.

Decedents:
Health information may be disclosed to funeral director, coroners or medical examiners to enable them to carry out their lawful duties.

Respond to Organ and Tissue Donation Requests:
We can share health information about you with organ procurement organizations.

Research:
We can use or share your information for health research.

Health and Safety:
Your health information may be disclosed to avert a serious threat to the health or safety of you or any other person pursuant to applicable law.

Government Functions:
Specialized government functions such as protection of public officials or reporting to various branches of the armed services that may require use or disclosure of protected health information.

Workers Compensation:
Your health information may be used or disclosed in order to comply with laws and regulations related to Workers Compensation.

 

Obligations of Ordot Dental

We are required to:
• Maintain the privacy and security of your protected health information;
• Provide you with this notice of its legal duties and privacy practices with respect to your health information;
• Abide by the terms of this notice;
• Let you know promptly if a breach occurs that may have compromised the privacy or security of your information;
• Notify you if we are unable to agree to a requested restriction on how your information by alternative means or at alternative locations; and
• Obtain your written authorization to use or disclose your health information for reasons other than those listed above and permitted under law.

We will not use or share your information other than as described in this notice unless you tell us 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.

Part 2 Records:

If this practice creates, receives, or maintains records that identify an individual as having sought or received Substance Use Disorder treatment, those records are afforded certain additional protections beyond standard HIPAA requirements. Patients have specific rights related to Substance Use Disorder records, including limitations on disclosures and the right to revoke certain authorizations, subject to applicable legal requirements. In general, such information may not be used or disclosed without the patient’s written consent, except as expressly permitted or required by law.

With respect to Part 2 Records, you have the right to provide consent when we use or share your information for most purposes. You may provide a single consent for all future uses or disclosures for treatment, payment, and health care operations purposes. You may provide consent for more limited purposes (for example, to only disclose information to another health care provider for your treatment); however, doing so may affect the services we can provide you or how you pay for services

You have the right to:
• Consent to most uses and disclosures of your health information
• Ask us to limit the information we share
• Get a copy of this privacy notice
• Discuss this notice with someone in our program
• Get a list of those with whom we’ve shared your electronic records*
• Get a list of health care providers who have received your information through certain third parties
• You have the right to a clear and obvious notice in advance of, and a choice about whether to receive, fundraising communications for our program.
• File a complaint if you believe your privacy rights have been violated

With your consent, we can use and share your information as we:
• Treat you
• Run our organization
• Bill for our services
• Fulfill your requests to share information with your consent
• Prevent multiple program enrollments
• Report about court-referred treatment
• Report to prescription drug monitoring programs

We may use and share your information without your consent as we:
• Communicate within our program and with our contractors
• Help with medical emergencies
• Help with public health
• Report crimes (and threats of crimes) on our premises and suspected child abuse and neglect
• Aid scientific research
• Respond to audits and evaluations of our program to improve the quality of our services, obtain needed credentials, and cooperate with oversight agencies for activities authorized by law, as long as those who view or receive the information agree to destroy or return the information when they are finished and agree not to use it against you.
• Assist cause of death inquiries as required or allowed by laws
• Respond to court orders
• Prevent or reduce crime in our program by reporting to law enforcement when a patient commits or threatens to commit a crime within our program or against our staff.
In all these circumstances, we must protect your information and limit how we use and share it.

You can ask us not to use or share certain health information for treatment, payment, or our health care operations after you have provided consent for all those purposes. We are not required to agree to your request, and we may say “no” if, for example, it could affect your care. If we agree to your request, we may still share this information in the event that you need emergency treatment.

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 health care operations with your health insurer. We will say “yes” unless a law requires us to share that information.

These additional protections apply only to information covered by 42 C.F.R. Part 2 and do not necessarily apply to all health information maintained by this practice.

When you consent to uses and disclosures for all future treatment and payment purposes and to run our business, we may share your information with other substance use disorder treatment programs, doctors’ offices, and health care businesses for those activities. If the person who receives it is subject to HIPAA, then they are allowed to use and share your information again without your consent for the purposes that HIPAA allows. Your information still cannot be used in legal proceedings against you unless (1) you consent or (2) based on a Part 2 court order and a subpoena (or similar legal requirement).

We must follow certain procedures before using or sharing your information for investigations and legal proceedings.
• We will not use or share your information or provide testimony about your information in any civil, administrative, criminal, or legislative proceedings against you without your written consent or a court order.
• We will only respond to a court order to use or share your health information if it is accompanied by a subpoena or other similar legal mandate requiring us to comply.
• We will only use or share your information in proceedings against you based on a court order after we have received notice and an opportunity to be heard or you tell us that you have received notice.
• We may use or share your information to respond to legal proceedings against our program based on a court order and you may not be notified in advance. You have the right to seek to overturn or change the court order after you learn about it.

Ordot Dental’s Responsibility for Part 2 Records:
• We are required to obtain your consent for most uses and sharing of your information.
• We are required by law to maintain the privacy and security of your information.
• We must 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 in this notice 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.

With respect to matters related to this Privacy Notification, you can file a complaint with Ordot Dental or 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 https://www.hhs.gov/hipaa/filing-a-complaint/index.html.

For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

We reserve the right to change our privacy practices and to make new provisions effective for all protected health information it maintains. As notices are revised, copies will be mailed to you within sixty (60) days of making the change.

If you have any questions, complaints, require additional information or if you do not want to provide your consent to Ordot Dental to use your protected health information for purposes of payment and/or health care operations, please contact:

Dr. Andrew B. Eusebio
Ordot Dental Clinic, LLP
P.O. Box 3280
Hagatna, Guam 96932
671-477-8215
Fax: 671-472-9420