ADHD ONLINE, LLC d/b/a Mentavi Health
I HEREBY CONSENT to the following terms and conditions related to the services that may be provided to me, or the patient for whom I represent and warrant I am the legal guardian, by ADO Medical, PC (“ADO”).
The Services
I understand the services include the completion of an online assessment for ADHD (“Assessment”) and other mental health disorders, which will be reviewed and interpreted by a doctorate-level psychologist, licensed physician, or licensed advanced practice provider (“Provider”) authorized to practice in the state where I am located; plus additional services including but not limited to psychological counseling, medication management, and coaching.
I understand that for an Assessment, ADO will facilitate the collection of my or my child’s (or other individuals for whom I am a legal guardian)(heretofore referred to as “dependent”) medical history through its online platform. ADO will then match the Assessment with a Provider. A portion of the assessment fee will be paid to Mentavi Health on behalf of ADO Medical and the Provider for various administrative services including billing, record management and other non-clinical support services. In consenting to, and agreeing to pay for these services, I understand, knowingly, and willingly accept the following terms and conditions.
Legal Medical Record
I understand I or my dependent is receiving online services from a Provider, and a legal medical record of the event will be created. I understand the services are strictly confidential and protected by applicable privacy laws. I confirm that the name and health information I provide is true to the best of my knowledge. If completing an Assessment on behalf of a dependent, I confirm that I have the legal right to consent to a medical evaluation for that person. I attest that I or my dependent are present in the state I select for the Assessment. I understand I can request a copy of my or my dependent’s records by submitting a signed records release form found on the ADO website. I may request that ADO correct health information that I feel is incorrect or incomplete. ADO may deny the request, but will provide an explanation within 60 days. I understand that I can review how ADO uses my medical information by reviewing the Notice of Privacy Practices and the ADO Privacy Policy. ADO will complete and provide me an evaluation and assessment for myself or my dependent based on the ADO questionnaire completed by me online. I understand that the Assessment will be the sole basis for the initial evaluation of ADHD unless my Provider requests additional information. I understand or my dependent may not have the opportunity for direct, indirect, or in-person contact with, or follow-up with, the Provider(s) completing, reviewing, and interpreting the Assessment. I or my dependent may not have the opportunity to discuss or challenge any diagnosis made or not made by the Provider. I understand that ADO does not guarantee that I or my dependent will be diagnosed with ADHD and that professional fees paid are exclusively for completion and review of an Assessment for ADHD and other mental health conditions. I understand that if a diagnosis is made, there will be additional fees related to medication management, counseling or other services. Most Assessments are reviewed and completed in 1-5 business days, but I understand that extenuating circumstances may delay the completion of my or my dependent’s Assessment and that a delay in processing the Assessment is not grounds for a refund.
Communication
By signing up for an account with ADO, I consent to allow ADO to email, call, or SMS text me about my account. Such communication may include: to reset my password, provide account verification, to notify me of portal messages or upcoming appointments, to follow-up with me about services in which I have indicated interest or have purchased, or to follow up with me about additional mental health and wellness services offered by ADO and its affiliates. Emails, calls, or SMS text messages will identify ADO or Mentavi Healthbut will not contain additional private health information, such as diagnosis or treatment information, unless I specifically authorize it.
I will have the opportunity to opt out of emails and SMS text messages at any time, and ADO will make a best-effort to prevent further communication within a week of receiving the opt-out request.
If I send an email or SMS text message to ADO requesting disclosure of private health information such as diagnosis or treatment information, I consent to allow ADO to respond with that information via SMS text message or email. I understand and accept the risks associated with sending private health information electronically.
Health/Medical Insurance
I understand that ADO does not directly participate with any type of health and/or medical insurance, including Medicaid and/or Medicare.
I understand that payment is due at the time of service.
ADO will provide me with paperwork to submit to my insurance company for reimbursement. I understand ADO does not guarantee that my insurance company will provide reimbursement for any services provided by or through ADO.
Refund Policy
I understand there will be no refunds once payment has been submitted and access to the assessment has been granted, even if I change my mind and choose not to finish the assessment.
I will not receive a refund if I or my dependent do not receive the diagnosis I was expecting.
I understand a $25 fee may be applied if, at the sole discretion of ADO, a refund is authorized.
Collections Policy
Unpaid fees, including charge-backs, will be forwarded to a collection agency.
At ADO’s discretion, credit card chargebacks will be charged a $25 charge-back fee in addition to merchant/bank chargeback fees of $19.62.
I agree to reimburse ADO for any collection fees, which may be based on a percentage at a maximum of 35% of the account balance, and all costs and expenses and reasonable attorneys’ fees ADO incurs in such collection efforts.
Privacy Policy
ADO has an internet Privacy Policy and a Notice of Privacy Practices. I understand a link to each can be found on the official ADO website.
I understand I will have the opportunity to download a copy of the Privacy Policy and the Notice of Privacy Practices.
Consent
I HEREBY ACCEPT ANY AND ALL RISK related to the services ADO provides and/or have been provided to me by ADO.
I acknowledge and understand that this Agreement applies to the persons and/or entities to be used by ADO and its employees and/or independent contractors in providing the services to me.
In consideration of my decision to hire these services from ADO, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows:
I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me, THE FOLLOWING ENTITIES OR PERSONS:
ADO owners, directors, officers, employees, contractors, volunteers, representatives, and agents.
I INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned in this document from any and all liabilities or claims made as a result of participation in this service, whether caused by negligence or otherwise.
I acknowledge that ADO and their directors, officers, volunteers, representatives, and agents are NOT responsible for the errors, omissions, acts, or failures to act of any party or entity conducting a specific activity on their or my behalf.
I understand while participating in this activity, I may choose or be requested to attach a photograph, which will remain part of the permanent record and protected in the same manner as any other personal health information.
This Agreement shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable Michigan law.
I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND SUBMITTING PAYMENT CONSTITUTES SIGNING THE AGREEMENT OF MY OWN FREE WILL.
CONSENT TO TELEHEALTH
BY CLICKING “I AGREE,” CHECKING A RELATED BOX TO SIGNIFY YOUR ACCEPTANCE, USING ANY OTHER ACCEPTANCE PROTOCOL PRESENTED THROUGH THE SERVICE OR OTHERWISE AFFIRMATIVELY ACCEPTING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS CONSENT. IF YOU DO NOT AGREE TO THIS CONSENT, DO NOT CREATE AN ACCOUNT OR USE THE SERVICE. YOU HEREBY GRANT AGENCY AUTHORITY TO ANY PARTY WHO CLICKS ON THE “I AGREE” BUTTON OR OTHERWISE INDICATES ACCEPTANCE TO THIS CONSENT ON YOUR BEHALF.
Purpose
The purpose of this consent form (“Consent”) is to provide you with information about telehealth and to obtain your informed consent to the use of telehealth in the delivery of healthcare services to you by health providers (“Providers”) using the online platform. Mentavi Health does not provide any medical services. Mentavi Health can store a request for medical services and forward that request to a licensed medical provider in your state.
Not for Emergencies
I understand that I should never use the Service in an emergency. I understand that in an emergency, I should dial 911 or go to an emergency department.
Consent to Use of Telehealth
I understand that telehealth involves the delivery of healthcare services using electronic communications, information technology or other means between a healthcare provider and a patient who are not in the same physical location.
I understand that telehealth may be used for diagnosis, treatment, follow-up and/or patient education, and may include, but is not limited to, one or more of the following: electronic transmission of medical records, photo images, personal health information or other data between a patient and a healthcare provider; interactions between a patient and healthcare provider via audio, video and/or data communications (such as secure messaging); use of output data from medical devices, sound and video files.
I understand that alternative methods of care are available to me, such as in-person services, and I may choose an alternative at any time. I can always discuss alternative options with my Providers. I understand that I am free to obtain a medical examination from another healthcare provider that is not associated with the Service.
I understand that I have the right to withdraw my consent to the use of telehealth without prejudicing my ability to receive any future care or treatment and without risking the loss or withdrawal of any health benefits to which I am entitled.
I understand that my withdrawal of consent will be effective upon receipt of written notice to my Providers, except that such withdrawal will not have any effect on any action taken by Mentavi Health or my Providers in reliance on this Consent before it received my written notice of withdrawal.
I understand that my withdrawal of consent will not affect any other provision of this Consent, and I will continue to be bound by this Consent.
Doctor-Patient Relationship
I understand that my Providers have the right to refuse to take responsibility for my or my dependent’s care if my Providers make a professional judgment that I am not a good candidate for this service. I understand that making a request for treatment (by completing a visit and making payment) or sending a message through the Service does not in and of itself create a duty of care or create a doctor-patient relationship with me or my dependent.
I understand that my Providers will take responsibility for my or my dependent’s care only after my Providers have reviewed the request for treatment, reviewed all information, and then subsequently determined that I or my dependent am a good candidate for the telehealth services.
I understand that there may be a delay before my Providers review any request for treatment and any messages I send.
Limited Scope of Service
I understand that by using the Service I or my dependent will receive care for a limited scope of services only.
I understand that by using the Service I or my dependent won’t receive any other medical services that go beyond the services offered by ADO. I need to seek other sources for other medical needs for me or my dependent. I understand that there are limitations in the provision of medical care and treatment via telehealth and technology, including the Service, and I or my dependent may not be able to receive diagnosis and/ or treatment through telehealth for every condition for which I seek diagnosis and/or treatment.
I understand that by using the Service for a telemedicine consultation, I or my dependent won’t have an in-person consultation and physical exam that might identify a medical condition that needs further investigation or immediate treatment.
Reliance On Information You Provide
I understand that by using the Service I or my dependent seek to enter into a relationship where my Providers rely upon information that I provide to decide whether or not the requested service is safe.
I understand that my Providers are limited in their ability to verify the information I provide and that the doctor will consider the information I provide to be accurate, true, and complete.
Anticipated Benefits
I understand that the use of telehealth may make it easier and more efficient for me or my dependent to access medical care and treatment for the conditions treated by my Providers, including being able to obtain medical care and treatment by my Providers at times that are convenient to me, and enabling me to interact with my Providers without the necessity of an in-office appointment.
Adverse Events
I understand that if I provide information that isn’t true and complete, then I or my dependent may be at greater risk of adverse events from taking the prescribed treatment.
I understand that all the information I provide when requesting a prescription is important in my Providers’ determination as to whether I or my dependent am a good candidate for particular treatments and for the service in general.
I understand that adverse events can be caused by a number of things, including an allergic reaction, side effects, or interactions between medications, smoking, or other things (e.g., supplements or recreational drugs) I or my dependent am taking.
I understand that technology used to deliver care, including the Service, may contain bugs or other errors, including ones that may limit functionality, produce erroneous results, or incorrect records, transmissions, data or content. I understand this could even extend to lost or corrupted records, transmissions, data or content, any or all of which could limit or otherwise impact the quality, accuracy and/or effectiveness of the medical care or other services that I or my dependent receive from my Providers.
I understand that my condition or my dependent’s may not be cured or improved, and in some cases, may get worse.
No Communication with a Doctor in Real Time
I understand that by using the Service some Services may be provided asynchronously and that I may not speak or message with my Providers in real-time.
I understand that I must check the Service for messages because this is the way that ADO will communicate important information. I understand that if I don’t check the Service regularly, then my or my dependent’s care may be delayed.
I understand that if I have any questions relating to my or my dependent’s care that aren’t urgent, I can message ADO.
Risk to Electronic Health Information
I understand that the electronic nature of the Service means that there’s a greater risk to the privacy of my or my dependent’s health information compared to visiting a traditional doctor’s office.
I understand that although ADO implements a wide range of administrative, physical, and technical safeguards to protect my or my dependent’s health information, ADO cannot guarantee the privacy and confidentiality of my health information.
I understand that the electronic systems used in the Service will incorporate network and software security protocols to protect the privacy and security of my information, and will include measures to safeguard data against intentional or unintentional corruption.
