Tangram, Inc.

NOTICE OF PRIVACY PRACTICES

Effective Date: January 31, 2011

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

If you have any questions about this notice, please contact the Privacy Officer of Tangram, 5155 Pennwood Dr, Indianapolis, IN 46205, 317-571-1042.

WHO WILL FOLLOW THIS NOTICE.

This notice describes our practices and that of:

• Any health care professional authorized to enter information into your file;
• All departments and units of Tangram;
• Any member of a volunteer group we allow to help you at Tangram; and
• All employees, staff and other personnel of Tangram.

All these entities, sites and locations follow the terms of this notice. In addition, these entities, sites and locations may share health information with each other for service provision, treatment, payment or Tangram operations for purposes described in this notice.

OUR PLEDGE REGARDING HEALTH INFORMATION.

We understand that health information about you is personal. We are committed to protecting health information about you. We create a record of the care and services you receive at Tangram. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by Tangram. Other Health Care Rehabilitation Facilities may have different policies or notices regarding use and disclosure of your health information.

This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of health information.

We are required by law to:

• Make sure that health information that identifies you is kept private;
• Give you this notice of our legal duties and privacy practices with respect to health information about you; and 
• Follow the terms of the notice that is currently in effect.

HOW WE ARE REQUIRED BY LAW TO DISCLOSE HEALTH INFORMATION ABOUT YOU.

As Required By Law. We will disclose health information about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety. We will use and disclose health information about you when we have a “Duty to Report” under state or federal law, because we believe that it is necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Public Health Risks. We will disclose health information about you for public health reporting required by federal or state law. These activities generally include the following:

• Prevent or control disease, injury or disability, report disease, injury, vital events such as birth or death and the conduct of public health surveillance, investigations and interventions;
• Report adverse events, product defects, to track products or enable product recalls, repairs and replacements and to conduct post-marketing surveillance and compliance with requirements of the Food and Drug Administration;
• Notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading disease; and
• Notify an employer about an individual who is a member of the employer’s workforce in certain limited situations, as authorized by law.

Abuse, Neglect or Domestic Violence. We are allowed to notify government authorities if we believe you are a victim of abuse, neglect or domestic violence. We will make this disclosure only when specifically required or authorized by law or when you agree to the disclosure.

Health Oversight Activities. We will disclose health information as required by law to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Judicial and Administrative Proceedings. We may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request or other lawful process, but only when we make reasonable efforts to either notify you about the request or to obtain an order protecting your health information.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we will disclose health information about you when properly ordered to do so by a court.

Law Enforcement. We will release health information if asked to do so by a law enforcement official, and if permitted by law:

• In response to a court order; 
• If required by state or federal law;
• To identify or locate a suspect, fugitive, material witness, or missing person;
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
• About a death we believe may be the result of criminal conduct;
• About criminal conduct while enrolled in Tangram services; and
• In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Specified Government Functions. In certain circumstances, the Federal regulations authorize us to use or disclose your health information to facilitate specified government functions relating to military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations, and inmates and law enforcement custody.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU.

The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

Treatment. We may use health information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, psychologists, nurses, social workers, therapists, technicians, medical students, or other Tangram personnel who are involved in provision of services to you. Different departments of Tangram also may share health information about you in order to coordinate the different things you need. We also may disclose health information about you to people outside Tangram, such as other health care providers involved in providing medical treatment for you and to people who may be involved in your medical care, such as family members, clergy or others we use to provide services that are part of your plan of care.

Payment. We may use and disclose health information about you so that the treatment and services you receive at Tangram, or other service providers from whom you receive treatment or services, may be billed to, and payment may be collected from, you, an insurance company or a third party. For example, we may need to give your health plan information about treatment or services you received at Tangram so your health plan will pay us or reimburse you for your treatment or services. We may also tell your health plan about a treatment or services you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

Health Care Operations. We may use and disclose health information about you for Tangram operations or to another service provider or health plan, if you have a relationship with that service provider or health plan. These uses and disclosures are necessary to run Tangram and make sure that all of our Clients receive quality services. For example, we may use health information to review our treatment and services and to evaluate the performance of our staff in providing services to you. We may also combine health information about many Clients to decide what additional services Tangram should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, social workers, therapists, nurses, psychologists, technicians, medical students, and other personnel for review and learning purposes. We may also combine the health information we have with health information from other Rehabilitation Facilities  to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of health information so others may use it to study health care and health care delivery without learning who the specific Clients are.

Appointment Reminders. We may use and disclose health information to contact you as a reminder that you have an appointment for treatment or services at Tangram or other services at Tangram.

Treatment Alternatives. We may use and disclose health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services. We may use and disclose health information to tell you about health-related benefits or services that may be of interest to you.

Fundraising Activities. We may use health information about you to contact you in an effort to raise money for Tangram and its operations. We may disclose health information to a foundation related to Tangram so that the foundation may contact you in raising money for Tangram. We only would release contact information, such as your name, address and phone number and the dates you received treatment or services at Tangram. If you do not want Tangram to contact you for fundraising efforts, you must notify the Tangram Privacy Officer, 5155 Pennwood Drive Indianapolis, IN 46205, in writing.

Facility Directory. We may include certain limited information about you in a facility directory while you are a Client at Tangram. This information may include your name, location, and services received.

Individuals Involved in Your Care or Payment for Your Care. We may release certain limited information about you to a friend or family member who is involved in your health care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

Coroners and Medical Examiners. We may disclose your health information to coroners and medical examiners for purposes of determining your cause of death or for other duties, as authorized by law. Funeral Directors. We may disclose your health information to funeral directors consistent with applicable law and, if necessary, to carry out their duties with respect to your funeral arrangements. If necessary to carry out their duties, we may disclose your health information prior to and in reasonable anticipation of your death.

Organ, Eye or Tissue Donation. We may disclose your health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue for the purpose of facilitating the donation and transplantation.

Research. Under certain circumstances, we may use and disclose health information about you for research purposes. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of health information, trying to balance the research needs with Clients’ need for privacy of their health information. Before we use or disclose  health information for research, the project will have been approved through this research approval process, but we may, however, disclose health information about you to people preparing to conduct a research project, for example, to help them look for Clients with specific health needs, so long as the health information they review does not leave Tangram. We may ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your services while at Tangram.

Limited Data Set. We may use or disclose a limited data set of your health information, that is, a subset of your health information for which all identifying information has been removed, for purposes of research, public health, or health care operations. Prior to our release, any recipient of that limited data set must agree to appropriately safeguard your health information.

Workers Compensation. We may release your health information for worker’s compensation or similar programs.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU.

You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy. You have the right to inspect and copy health information that may be used to make decisions about your services. Usually, this includes medical and billing records, but does not include psychotherapy notes.

To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to the Tangram Privacy Officer, 5155 Pennwood Drive, Indianapolis, IN 46205. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, under some circumstances you may request that the denial be reviewed. Another licensed health care professional chosen by Tangram will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend. If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for Tangram.

To request an amendment, your request must be made in writing and submitted to Tangram Privacy Officer, 5155 Pennwood Drive, Indianapolis, IN 46205. In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the health information kept by or for Tangram; 
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request an “Accounting of Disclosures.” This is a list of the disclosures we made of health information about you. To request this list or accounting of disclosures, you must submit your request in writing to Tangram Privacy Officer, 5155 Pennwood Drive, Indianapolis, IN 46205. Your request must state a time period that may not be longer than six years and may not include dates before February 26, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a specific treatment or service you received.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to Tangram Privacy Officer, 5155 Pennwood Drive, Indianapolis, IN 46205. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

Right to Request Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at home or by mail. To request confidential communications, you must make your request in writing to Tangram Privacy Officer, 5155 Pennwood Drive, Indianapolis, IN 46205. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. Right to a Paper Copy of This Notice.

You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy of this notice, contact the Tangram Privacy Officer at 317-571-1042.

CHANGES TO THIS NOTICE

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in each of our facilities. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register for services at Tangram, we will offer you a copy of the current notice in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with Tangram or with the Secretary of the Department of Health and Human Services. To file a complaint with Tangram, contact the Tangram Privacy Officer, 5155 Pennwood Drive, Indianapolis, IN 46205, 317-571-1402. All complaints must be submitted in writing.

You will not be penalized or retaliated against in any way for filing a complaint.

OTHER USES OF HEALTH INFORMATION

Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.