TERMS AND CONDITIONS
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.
These Terms and Conditions govern your access to the Services and the websites located at www.adhonline.com and www.mentavi.com and any other U.S. websites on which we post these Terms and Conditions and any affiliated mobile applications on which we post these Terms and Conditions (collectively, the “Platform”). The platform is owned and operated by Mentavi, Inc. and/or its subsidiaries (“Mentavi”).
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, medical management, and coaching (“Services”). All Services (depending on your location at the time you receive the Services) are provided by ADO Medical, P.C., ADO Medical of Kansas, P.A. , ADO Medical of California, P.C., ADO Medical of New Jersey, P.C. or ADO Medical of Texas, P.A. (“Medical Groups”) and their contracted or employed providers (“Providers”). Mentavi does not own or have any ownership interest in any of the Medical Groups and the Medical Groups do not own or have any ownership interest in Mentavi.
I understand that for an Assessment, the Medical Groups use the Platform to 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. The Platform will then match the Assessment with a Provider. A portion of the assessment fee will be paid to Mentavi Health on behalf of the Medical Groups and the Providers 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
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.
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.
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.
Unpaid fees, including charge-backs, may 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.
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.