Blog

Last modified: March 7, 2025
Introduction
BLACKSTONE MEDICAL SERVICES, LLC (the “Company” or “We”) respects your privacy
and is committed to protecting it through our compliance with this privacy policy (the “Policy”).
The Policy should be read in connection with the Sleep Health Application End User License
Agreement (the “EULA”), HIPAA Privacy Practices Policy, Medical Benefits Assignment, any
applicable delivery ticket(s), and any terms and conditions or terms of use applicable to the
Blackstone Medical Services Sleep Health Application (the “App”), the Company’s website (the
“Website”), and any other applications or websites of the Company used or accessed by you in
connection with the home sleep study (the “Services”).
This Policy describes:
· The types of information we may collect or that you may provide when you download,
access, register with, or use the App.
· Our practices for collecting, using, maintaining, protecting, and disclosing that
information.
This policy applies only to information we collect in the App and in email, text, and other
electronic communications sent through or in connection with the App.
This Policy DOES NOT apply to information that:
· We collect offline or on any other Company applications or websites which are not
otherwise intended to be used or accessed in connection with the Services.
· You provide to or is collected by any third party.
Our websites and applications, and other third parties, may have their own privacy policies,
which we encourage you to read before providing information on or through them.
Please read the Policy carefully to understand our policies and practices regarding your
information and how we will treat it. If you do not agree with our policies and practices, do not
download, register with, or use this App.
BY CLICKING “I AGREE” OR OTHERWISE INDICATING YOUR CONSENT WHEN
PROMPTED TO DO SO BY THE APP OR BY USING THE WEBSITE IN CONNECTION
WITH THE SERVICES, YOU AGREE TO THIS POLICY.
This Policy may change from time to time in the sole discretion of the Company, in accordance
with the terms set forth herein. Your continued use of this App after we revise the Policy means
you accept those changes, so please check the Policy periodically for updates.
Children Under the Age of 18
The Services are not intended for children under eighteen (18) years of age, and we do not
knowingly collect Personal Health Information (as defined below) from children under eighteen
(18). If we learn we have collected or received Personal Health Information from a child under
eighteen (18) without verification of parental consent, we will promptly delete such information.

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If you believe we might have any information from or about a child under eighteen (18), please
contact us using the contact information below.
Information We Collect and How We Collect It
We collect information from and about users of our App:
· Directly from you when you provide it to us.
· Automatically when you use the App.
· When you authorize us to receive your information from third parties.

Information You Provide to Us
When you download, register with, or use this App, we may ask you provide information:
· By which you may be personally identified (“PII”), such as:
· Personal Identifiers (such as your name, postal address, email address, telephone
number, social security number)
· Personal Information Categories, as listed in Cal. Civ. Code Sec. 1798.80(e)
(including but not limited to your name, driver’s license number, insurance policy
number, or other information which may overlap with other categories of information
collected, as set forth in this policy)
· Protected Classification Characteristics, as protected under state or federal law
(including but not limited to age, race, sex, medical conditions, physical or mental
disability)
· Commercial Information (such as records of products/services purchased, obtained or
considered, or other purchasing or consuming histories or tendencies)
· Biometric Information (including genetic, physiological, behavioral, and biological
characteristics, or activity patterns used to extract a template or other identifier or
identifying information, such as, fingerprints, faceprints, and voiceprints, iris or retina
scans, keystroke, gait, or other physical patterns, and sleep, health, or exercise data)
· Internet or Network Activity (browsing history, search history, information on your
interaction with a website, application, or advertisement)
· Geological Data (such as your physical location or movements)
· Sensory Data (audio, electronic, visual, thermal, olfactory, or similar information)
· Professional or Employment Related Information (occupation)
· Inferences Drawn from PII (profile reflecting a person’s preferences, characteristics,
psychological trends, predispositions, behavior, attitudes, intelligence, abilities, and
aptitudes)
· Information related to your medical history, including information, whether oral or
recorded in any form or medium that is created or received by a health care provider,

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health plan, public health authority, employer, life insurer, school or university, or
health care clearinghouse and relates to the past, present, or future physical or mental
health or condition of an individual, the provision of health care to an individual, or
the past, present, or future payment for the provision of health care to an individual,
or any other information that is considered “protected health information” under
certain state laws and federal laws such as HIPAA and HITECH (collectively,
“Personal Health Information” or “PHI”).
· That is about you but individually does not identify you.
This information includes information that you provide:
· By filling in forms or responding to prompts for information in the App. This includes
information provided at the time of registering to use the App and/or subscribing to or
electing to participate in any of our services, including requesting further services.
· Upon reporting a problem with the App.
· In correspondence with us. We may retain records and copies of your correspondence
(including email addresses and phone numbers), if you contact us.
· By responding to surveys or questionnaires that we might ask you to complete for
research, customer satisfaction, or other purposes.
· By responding to bill pay notifications. You may be required to provide financial
information to our payment processor, at which time, the terms of service of such
payment processor will be provided.
We abide by the following principles with respect to your information:
 The Company will not collect any more PII than is considered necessary for the purposes
collected
 PII is used for the specific purposes set forth in this Policy
 PII is not stored longer than is deemed necessary
 PII is not shared with any third parties except as provided in this Policy
 The Company will abide by any applicable law and/or Business Associate Agreement
with respect to your PHI, notwithstanding this Policy

Automatic Information Collection and Tracking
When you download, access, and use the App, it may use technology to automatically collect
information about your interaction with and use of the App or Website, including:
· Usage Details. When you access and use the App, we may automatically collect certain
details of your access to and use of the App, including traffic data, location data, logs,
and other communication data and the resources or features that you access and use on or
through the App.

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· Device Information. We may collect information about your mobile device and internet
connection, including the device’s unique device identifier, IP address, operating system,
browser type, mobile network information, and the device’s telephone number.
· Location Information. This App collects real-time information about the location of
your device.
· Stored Information and Files. The App also may access metadata and other information
associated with other files stored on your device. This may include, for example,
photographs, audio and video clips, and similar information.
· Behavioral Tracking. The App may use technologies to collect information about your
activities over time and across third-party websites, apps, or other online services.
· Security. Certain data collection may be used to protect you and us and to detect any
violations of this Policy or the Agreement.
· Performance. The App may use technologies to ensure optimal use of the Services and
the App or Website.
IF YOU DO NOT WANT US TO COLLECT THIS INFORMATION DO NOT DOWNLOAD
THE APP OR DELETE IT FROM YOUR DEVICE.
We do not control third parties’ collection or use of your information to serve interest-based
advertising. However, these third parties may provide you with ways to choose not to have your
information collected or used in this way. You can opt out of receiving targeted ads from
members of the Network Advertising Initiative (“NAI”) on the NAI’s website, located at
https://optout.networkadvertising.org/?c=1.

Information Collection and Tracking Technologies
The technologies we use for automatic information collection may include:
· Cookies. A cookie is a small file placed on your smartphone. It may be possible to refuse
to accept mobile cookies by activating the appropriate setting on your smartphone.
However, if you select this setting you may be unable to access certain parts of our App.
· Web Beacons. Pages of the App and our emails may contain small electronic files known
as web beacons that permit the Company, for example, to count users who have visited
those pages or opened an email and for other related app statistics (for example,
recording the popularity of certain content and verifying system and server integrity).

Third-Party Information Collection
When you use the App or its content, certain third parties may use automatic information
collection technologies to collect information about you or your device. These third parties may
include:
· Analytics companies.
· Your mobile device manufacturer.

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· Your mobile service provider.
· Advertisers, ad networks, or ad servers.
These third parties may use tracking technologies to collect information about you when you use
this App. The information they collect may be associated with your Personal Health Information
or they may collect information, including Personal Health Information, about your online
activities over time and across different websites, apps, and other online services websites. They
may use this information to provide you with interest-based (behavioral) advertising or other
targeted content.
We do not control these third parties’ tracking technologies or how they may be used. If you have
any questions about an advertisement or other targeted content, you should contact the
responsible provider directly.

How We Use Your Information
We may use information that we collect about you or that you provide to us, including any
Personal Health Information, to:
· Provide you with the Services, and any other information, products or services that you
request from us.
· Fulfill any other purpose for which you provide it.
· Give you notices about your account/subscription, including expiration and renewal
notices, as applicable.
· Carry out our obligations and enforce our rights arising from any contracts entered into
between you and us, including for billing and collection.
· Notify you when App updates are available, and of changes to any products or services
we offer or provide though it.
· Notify you of any updates to our policies and terms of service, as applicable.
The usage information we collect helps us to improve our Services and to deliver a better and
more personalized experience by enabling us to:
· Estimate our audience size and usage patterns.
· Store information about your preferences, allowing us to customize our App according to
your individual interests.
· Speed up your searches.
· Recognize you when you use the App.
We may use location information we collect to provide you information in connection with use
of the Services, such as identifying the nearest courier for purposes of shipping the home sleep
test device.
We may use your information to contact you about other goods and services we offer that may
be of interest to you.

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We may use the information we collect to display advertisements to our advertisers’ target
audiences. Even though we do not disclose your Personal Health Information for these purposes
without your consent, if you click on or otherwise interact with an advertisement, the advertiser
may assume that you meet its target criteria.

Disclosure of Your Information
We may disclose aggregated information about our users, and information that does not identify
any individual or device, without restriction.
SUBJECT TO APPLICABLE STATE AND FEDERAL LAW, INCLUDING BUT NOT
LIMITED TO OUR OBLIGATIONS UNDER HIPAA AND HITECH, WE MAY LICENSE,
SELL, OR OTHERWISE SHARE AGGREGATED, DE-IDENTIFIED VERSIONS OF YOUR
PHI AND OTHER DATA (“DEIDENTIFIED INFORMATION”) WITH OUR
SUBSIDIARIES, AFFILIATES, PARTNERS, CUSTOMERS, INVESTORS, AND
CONTRACTORS FOR ANY PURPOSE. YOU AGREE AND ACKNOWLEDGE THAT
COMPANY IS THE SOLE AND EXCLUSIVE OWNER OF ANY DEIDENTIFIED
INFORMATION CREATED BY COMPANY AND THAT YOU HAVE NO OWNERSHIP OR
OTHER INTELLECTUAL PROPERTY RIGHTS IN OR TO SUCH DEIDENTIFIED
INFORMATION.
In addition, we may receive or disclose other information, including Personal Health
Information, that we collect or you provide:
· To your physician and insurance carrier, as applicable.
· To our subsidiaries and affiliates who are bound by contractual obligations to keep PHI
and other information confidential and use it only for the purposes for which we disclose
it to them.
· To contractors, service providers, and other third parties we use to support our business
and provide the services, including durable MyCardio, LLC and medical equipment
providers and who are bound by contractual obligations to keep PHI and other
information confidential and use it only for the purposes for which we disclose it to them.
· To our third-party payment provider, as applicable.
· To a buyer or other successor in the event of a merger, divestiture, restructuring,
reorganization, dissolution, or other sale or transfer of some or all of the Company’s
assets, whether as a going concern or as part of bankruptcy, liquidation, or similar
proceeding, in which Personal Health Information held by the Company about our App
users is among the assets transferred.
· To fulfill the purpose for which you provide it.
· For any other purpose disclosed by us when you provide the information.
· With your consent.
· To comply with any court order, law, or legal process, including to respond to any
government or regulatory request.

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· To enforce our rights arising from any contracts entered into between you and us,
including the EULA, and for billing and collection.
· If we believe disclosure is necessary or appropriate to protect the rights, property, or
safety of the Company our customers or others. This includes exchanging information
with other companies and organizations for the purposes of fraud protection and data
security.

Accessing and Updating Your Personal Health Information
You can review and change your PHI or other information by logging into the App and visiting
your account profile page. We cannot change your PHI or other information nor can we delete
your PHI or other information except by also deleting your user account. We may deny access to
your PHI or Personal Health Information when required by law or if we believe such access
would cause the PHI or other information of a third party to be revealed.
You may also contact us to request access to, correct, or delete any Personal Health Information
that you have provided to us; provided, however that certain information we may not be able to
delete without deleting your account. We may not accommodate a request to change information
if we believe the change would violate any law or legal requirement or cause the information to
be incorrect.

Data Security
We have implemented measures designed to secure your Personal Health Information and other
information from accidental loss and from unauthorized access, use, alteration, and disclosure.
Information you provide to us is stored on our secure database and all medical records are
encrypted.
The safety and security of your information also depends on you. Where we have given you (or
where you have chosen) a password for access to certain parts of our App, you are responsible
for keeping this password confidential. We ask you not to share your password with anyone.
Unfortunately, the transmission of information via the internet and mobile platforms is not
completely secure. Although we do our best to protect your Personal Health Information, we
cannot guarantee the security of your Personal Health Information transmitted through our App.
Any transmission of Personal Health Information is at your own risk. We are not responsible for
circumvention of any privacy settings or security measures we provide.

Changes to Our Privacy Policy
We may update this Policy from time to time. If we make material changes to how we treat our
users’ Personal Health Information, we will post the new privacy policy on this page with a
notice that the Policy has been updated.
The date the privacy policy was last revised is identified at the top of the page. You are
responsible for periodically visiting this privacy policy to check for any changes.

Contact Consent.
By clicking Select, Agree or logging into the Blackstone SleepHealth (Android/iOS) or Blackstone Sleep (iOS) app, I am providing my express written consent to permit Blackstone Medical Services, staff, contractors and subsidiaries, to contact me by telephone, email or text (SMS Messages), including through automated technology.

SMS Messaging
You are able to sign up for SMS messages – please note that messaging frequency will vary,
and message and data rates may apply. You can text HELP for help, or STOP to stop at any time.
The phone number and SMS consent obtained for the purpose of SMS is not shared with third parties for marketing purposes.

SMS Terms of Service

By opting into SMS from a web form or other medium, you are agreeing to receive SMS messages from Blackstone Medical Services. This includes SMS messages for appointment scheduling, appointment reminders, post-visit instructions, lab notifications, and billing notifications. Message frequency varies. Message and data rates may apply. See privacy policy at https://www.wpt-ydlv.199-250-204-138.cpanel.site/privacy-policy-2/ Message HELP for help. Reply STOP to any message to opt out.

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Links / URL’s
 Sleep Health Application End User License Agreement
 HIPAA Privacy Practices Policy
 Medical Benefits Assignment
 HIPAA Marketing Authorization

 

Contact Information
To ask questions or comment about the Policy and our privacy practices, contact us at:

1-888-710-2727 or email us at:  customersupport@blackstonemedicalservices.com

Refund Policy
After you have completed the test, you will be required to return the testing device to Blackstone in the
package provided. Once Blackstone receives your device, Blackstone will then conduct an accounting of
all testing costs, fees and payments made associated with your account. After you have returned the
device, you should contact your insurance company to determine what portion if any of the testing fee
is not covered by insurance and for which you are responsible. If the amount for which you are
responsible more than your initial payment to Blackstone, you will have a balance due. If the amount
for which you are responsible is less than your initial payment you made to Blackstone, you may be
entitled to an overpayment refund.

If Blackstone is holding any overpayment funds on your behalf, Blackstone will access an administrative
fee of $10.00 per month for every month in which Blackstone is holding any overpayment after the
conclusion of the sleep test. The administrative fee is necessary to cover the administrative expenses
incurred in conducting a final accounting and in maintaining your account. However, if you have an
overpayment being held by Blackstone, and you contact Blackstone within 90 days’ following the
conclusion of your test to request your refund, the administrative fee will be waived.
However, if after 90 days you have not contacted Blackstone to request your refund, all accrued
administrative fees will be applied to your account, and your credit balance will be deducted
accordingly.  Your account will thereafter continue to be assessed the monthly administrative fee until
your account balance reaches $0.00 or you contact Blackstone Medical Services to request the refund of
any overpayment you may have.

If Blackstone issues an overpayment refund check and you do not cash it within 90 days of issuance, the
check will thereafter be rendered void, the administrative fee will be applied to your account, and your
credit balance will be deducted accordingly.  Your account will thereafter continue to be assessed the
monthly administrative fee until your account balance reaches $0.00 or you contact Blackstone Medical
Services to request that we issue another check for the remaining credit balance. In the event
Blackstone Medical Services does issue a second check, this process will begin again until that check has
been cashed or your account reaches $0.00.

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QUICK NOTES

1. Complete the 2-night test within 5 DAYS of receiving it and use the provided return label to return it to the proper carrier. If the label says UPS, it must be returned to a UPS store or drop-box. If the label is from the USPS (post office) you can put it in your mailbox. Again, the device must be returned within 5 days of receiving it to avoid late fees.

 

2. BEFORE you do the test, please watch the instructional video on how to do the test on our website: www.blackstonemedicalservices.com under the “Patient Support” section.

 

 

3. If you need HELP with the test, PLEASE call us at our customer service phone number 1-888-710-2727.

 

 

4. Please print name, sign and date the DELIVERY TICKET and return with test.

 

 

 

5. If the test is hooked-up correctly, you should see a GREEN LIGHT on the device and a RED LIGHT on your finger.

 

 

 

6. The device has a maximum record time, so it is not UNCOMMON for the device to SHUT OFF during the 2nd NIGHT. The device may be removed at this point.

 

 

7. If you get up to use the restroom or get a drink during the night, leave the testing device on and recording and return to bed when done. You do not need to take it off or turn it off until done sleeping for the night.

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1. Complete the 2-night test within 5 DAYS of receiving it and use the provided return label to return it to the proper carrier. If the label says UPS, it must be returned to a UPS store or dropbox. If the label is from the USPS (post office) you can put it in your mailbox. Again, the device must be returned within 5 days of receiving it to avoid late fees.

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2. BEFORE you do the test, please watch the instructional video on how to do the test on our website: www.blackstonemedicalservices.com under the “Patient Support” section.

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3. If you need HELP with the test, PLEASE call us at our customer service phone number 1-888-710-2727.

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4. Please print name, sign and date the DELIVERY TICKET and return with test.

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5. If the test is hooked-up correctly, you should see a GREEN LIGHT on the device and a RED LIGHT on your finger.

[/et_pb_text][/et_pb_column][/et_pb_row][et_pb_row column_structure=”2_3,1_3″ _builder_version=”4.5.5″ _module_preset=”default” custom_padding=”||3px|||”][et_pb_column type=”2_3″ _builder_version=”4.5.5″ _module_preset=”default” background_enable_color=”off” custom_padding=”|18px||0px|false|false”][et_pb_text _builder_version=”4.5.5″ _module_preset=”default” text_font=”Poppins||||||||” text_text_color=”#000000″ text_font_size=”16px” background_color=”#ffffff” min_height=”209px” max_height=”226px” custom_margin=”|||16px||” custom_padding=”99px|45px|54px|||”]

6. The device has a maximum record time, so it is not UNCOMMON for the device to SHUT OFF during the 2nd NIGHT. The device may be removed at this point.

[/et_pb_text][/et_pb_column][et_pb_column type=”1_3″ _builder_version=”4.5.5″ _module_preset=”default”][et_pb_image src=”http://www.blackstonemedicalservices.com/wp-content/uploads/classic-metallic-chrome-mechanical-analog-stopwatc-8VKV6Q9.jpg” alt=”Plan your test” title_text=”classic-metallic-chrome-mechanical-analog-stopwatc-8VKV6Q9″ align=”center” force_fullwidth=”on” _builder_version=”4.5.5″ _module_preset=”default” min_height=”209px” max_height=”226px” custom_padding=”|0px||||”][/et_pb_image][/et_pb_column][/et_pb_row][et_pb_row column_structure=”1_3,2_3″ _builder_version=”4.5.5″ _module_preset=”default” custom_padding=”||3px|||”][et_pb_column type=”1_3″ _builder_version=”4.5.5″ _module_preset=”default” background_color=”#8f8f8f” custom_padding=”|18px||0px|false|false”][et_pb_image src=”http://www.blackstonemedicalservices.com/wp-content/uploads/woman-drinking-a-glass-of-water-at-night-E8CM6WF.jpg” alt=”Plan your test” title_text=”woman-drinking-a-glass-of-water-at-night-E8CM6WF” force_fullwidth=”on” _builder_version=”4.5.5″ _module_preset=”default” min_height=”209px” max_height=”226px”][/et_pb_image][/et_pb_column][et_pb_column type=”2_3″ _builder_version=”4.5.5″ _module_preset=”default” background_color=”#8f8f8f”][et_pb_text _builder_version=”4.5.5″ _module_preset=”default” text_font=”Poppins||||||||” text_text_color=”#ffffff” text_font_size=”16px” background_enable_color=”off” min_height=”209px” max_height=”226px” custom_margin=”|||16px||” custom_padding=”71px|45px|50px|||”]

7. If you get up to use the restroom or get a drink during the night, leave the testing device on and recording and return to bed when done. You do not need to take it off or turn it off until done sleeping for the night.

[/et_pb_text][/et_pb_column][/et_pb_row][/et_pb_section]

THIS DEVICE IS THE PROPERTY OF BLACKSTONE MEDICAL SERVICES. PROPER CARE AND HANDLING OF THIS DEVICE IS ESSENTIAL AS THE DATA INSIDE THIS DEVICE WILL BE USED TO REPORT YOUR STUDY.

HOW LONG DO I HAVE TO DO THE STUDY?

YOU HAVE

FROM THE DAY YOU RECEIVE THIS DEVICE, 5 (FIVE) CALENDAR DAYS BASED ON TRACKING INFORMATION, TO DO THE STUDY AND UP TO 2 DAYS TO RETURN IT BEFORE WE CONSIDER THE DEVICE TO BE SUBJECT TO A LATE FEE OR LOST.

IF YOU HAVE ANY DIFFICULTY COMPLETING THE TEST IN THAT TIME, CONTACT US EITHER BY TELEPHONE 1-888-710-2727, LIVE CHAT DURING BUSINESS HOURS (MONDAY – FRIDAY, 8AM – 5PM EST) OR EMAIL CUSTOMERSUPPORT@BLACKSTONEMEDICALSERVICES.COM LET US KNOW WHAT IS HAPPENING.

WE ASK THAT YOU IMMEDIATELY RETURN THE DEVICE AND ALL OF THE CONTENTS THAT WERE ORIGINALLY DELIVERED TO YOU AFTER YOU HAVE COMPLETED THE TEST, USING THE PREPAID SHIPPING LABEL THAT HAS BEEN PROVIDED.

LATE FEE
AFTER 7 (SEVEN) CALENDAR DAYS, IF WE HAVE NOT HEARD FROM YOU, YOU WILL BE CHARGED A LATE FEE OF $25.00 (TWENTY FIVE DOLLARS) PER DAY UP TO $125.00 (ONE HUNDRED AND TWENTY-FIVE DOLLARS) (DAY 12) AFTER WHICH TIME THE DEVICE IS CONSIDERED TO BE LOST AND YOU WILL BE RESPONSIBLE FOR THE FULL REPLACEMENT COST OF THE DEVICE.

REPLACEMENT COST FOR UNRETURNED DEVICES IF THE DEVICE IS NOT RETURNED AFTER 12 DAYS, AND WE HAVE NOT HEARD FROM YOU OR YOU HAVE NOT RESPONDED TO REQUESTS TO EITHER COMPLETE THE STUDY OR RETURN THE DEVICE, YOU WILL BE CHARGED $1,500.00 (FIFTEEN HUNDRED DOLLARS) FOR THE FULL REPLACEMENT COST OF THE DEVICE AND ITS CONTENTS AFTER THE 12 DAYS HAVE PASSED.

550 N. REO STREET, SUITE 106, TAMPA, FL 33609
PH: 813.831.2727
Toll-Free: 888.710.2727
FX: 888.239.4616

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.

A federal regulation, known as the “HIPAA Privacy Rule”, requires that we provide detailed notice in writing of our privacy

practices.

As a patient, you have the following rights:

1. The right to inspect and copy your information

2. The right to request corrections to your information

3. The right to request that your information be restricted

4. The right to request confidential communications

5. The right to a report of disclosures of your information; and

6. The right to a paper copy of this notice

Uses and/or disclosures which do not require your written authorization may include:

Treatment: We will use your health information to make decisions about the provision, coordination or management or your

healthcare. It may also be necessary to share your health information with another health care provider whom we need to

consult with respect to your care.

Payment: We may need to use or disclose information in your health record to obtain reimbursement from you, from your

health insurance carrier, or from another insurer for our services rendered to you. This may include determinations of eligibility

or coverage under the appropriate health plan, pre-certification and pre-authorization of services or review of services for the

purpose of reimbursement. This information may also be used for billing, claims management and collection purposes, and

related healthcare data processing through our system.

Operations: Your health records may be used in our business planning and development operations, including improvements

in our methods of operation, and general administrative functions. We may also use the information in our overall compliance

planning, healthcare review activities, and arranging for local and auditing functions.

There are certain other circumstances under which we may use or disclose your health information without first obtaining your

Acknowledgment or Authorization. Those circumstances generally involve public health and oversight activities, law enforcement

activities, judicial and administrative proceedings, and in the event of death. Specifically, we may be required to

report to certain agencies information concerning certain communicable diseases, sexually transmitted diseases or HIV/AIDS

status. We may also be required to report instances of suspected or documented abuse, neglect or domestic violence. We are

required to report to appropriate agencies and law-enforcement officials information that you or another person is in

immediate threat of danger to health or safety as a result of violent activity. We must also provide health information when

ordered by a court of law to do so.

Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend

or any other person you identify, your protected health information that directly relates to that person’s involvement in your

health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we

determine that it is in your best interest based on our professional judgment. We may use or disclose protected health

information to notify or assist in notifying a family member, personal representative or any other person that is responsible for

our care of your location, general condition or death. Finally, we may use or disclose your protected health information to an

authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other

individuals involved in your healthcare.

Communication Barriers and Emergencies: We may use and disclose your protected health information if we attempt to

obtain consent from you but are unable to do so because of substantial communication barriers and we determine, using

professional judgment, that you intend to consent to use or disclosure under the circumstances. We may use or disclose your

protected health information in an emergency treatment situation. If this happens, we will try to obtain your consent as soon

as reasonably practicable after the delivery of treatment. If we are required by law or as a matter of necessity to treat you, and

we have attempted to obtain your consent but have been unable to obtain your consent, we may still use or disclose your

protected health information to treat you.

Except as indicated above, your health information will not be used or disclosed to any other person or entity without your

specific authorization, which may be revoked at any time. In particular, except to the extent disclosure has been made to

governmental entities required by law to maintain the confidentiality of the information, information will not be further

disclosed to any other person or entity with respect to information concerning mental health treatment, drug and alcohol

abuse, HIV/AIDS or sexually transmitted diseases that may be contained in your health records. We likewise will not disclose

your health-record information to an employer for purposes of making employment decisions, to a liability insurer or attorney

as a result of injuries sustained in an automobile accident, or to educational authorities, without you written authorization.

You have certain rights regarding your health record information, as follows:

(1) You may request that we restrict the uses and disclosures of your health record information for treatment,

payment and operations, or restrictions involving your care or payment related to that care. We are not

required to agree to the restriction; however, if we agree, we will comply with it, except with regard to

emergencies, disclosure of the information to you, or if we are otherwise required by law to make a full

disclosure without restriction.

(2) You have a right to request receipt of confidential communications of your medical information by an alternative

means or at an alternative location. If you require such an accommodation, you may be charged a fee for the

accommodation and will be required to specify the alternative address or method of contact and how payment

will be handled.

(3) You have the right to inspect, copy and request amendments to your health records. Access to your health

records will not include psychotherapy notes contained in them, or information compiled in anticipation of or for

use in a civil, criminal or administrative action or proceeding to which your access is restricted by law. We will

charge a reasonable fee for providing a copy of your health records, or a summary of those records, at your

request, which includes the cost of copying, postage, and preparation or an explanation or summary of the

information.

(4) All requests for inspection, copying and/or amending information in your health records, and all requests related

to your rights under this Notice, must be made in writing and addressed to the Privacy Officer at our address.

We will respond to your request in a timely fashion.

(5) You have a limited right to receive an accounting of all disclosures we make to other persons or entities of your

health information except for disclosures required for treatment, payment and healthcare operations,

disclosures that require and Authorization, disclosure incidental to another permissible use or disclosure, and

otherwise as allowed by law. We will not charge you for the first accounting in any twelve-month period;

however, we will charge you a reasonable fee for each subsequent request for an accounting within the same

twelve-month period.

(6) If this notice was initially provided to you electronically, you have the right to obtain a paper copy of this notice

and to take one home with you if you wish.

You may file a written complaint to us or to the Secretary of Health and Human Services if you believe that your privacy rights

with respect to confidential information in your health records have been violated. All complaints must be in writing and must

be addressed to the Privacy Officer (in the case of complaints to us) or to the person designated by the U.S. Department of

Health and Human Services if we cannot resolve your concerns. You will not be retaliated against for filing such a complaint.

More information is available about complaints at the government’s website, http://www.hhs.gov/ocr/hipaa.

All questions concerning this Notice or requests made pursuant to it should be addressed to

officemanager@blackstonemedicalservices.com.