Privacy Policy Acknowledgment

I hereby acknowledge that I have received and reviewed a copy of Gateway Pediatric Therapy’s Notice of Privacy Practices explaining:

• How this office will use and disclose my Protected Health Information
• My privacy rights with regard to my Protected Health Information
• Gateway’s obligation concerning the use and disclosure of my Protected Health
Information.

I understand that the Notice of Privacy Practices may be revised at any time, and that I am entitled to
receive a copy of any revised Notice of Privacy Practices upon request. I also understand that if I have any
questions or complaints, I may contact:

Gateway Pediatric Therapy, LLC
32100 Telegraph Rd, Suite 205
Bingham Farms, MI 48025
ATTN: Ombudsman

Toll Free: (855) 662-7233 ext: 6238754874
Email: compliance@gatewaypediatrictherapy.com

You may also contact the Secretary of the U.S Department of Health and Human Services with any
concerns regarding our privacy and security policies and procedures. Please contact our office for
information on how to contact the U.S Department of HHS. https://ocrportal.hhs.gov/.

Client Name:
Parent/Guardian Name:
Relationship to Client:
Signature
Date