Mentavi, Inc.
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.
The Services
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 may include the completion of an online assessment for ADHD and other mental health disorders (“Assessment”), 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 or completion of an online mental wellness snapshot which is evaluated and scored through the use of proprietary scoring systems and diagnostic and treatment protocols (“Snapshot”)l; plus additional services including but not limited to psychological counseling, medical management, and coaching (“Services”). Some Services (depending on your location at the time you receive the Services and the Service purchased) 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 a Snapshot, neither I nor my dependent is receiving medical services from the Medical Group or Mentavi. I understand that for the Snapshot, Mentavi uses the Platform to facilitate the collection of medical history and medical information through its online platform. The Platform will then use proprietary scoring systems and diagnostic and treatment protocols to evaluate my responses. I understand that no health care provider reviews the Snapshot responses or results and that no health care provider and patient relationship is created between myself and Mentavi or the Medical Group. In consenting to, and agreeing to pay for these services, I understand, knowingly, and willingly accept the following terms and conditions.
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 and medical information 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
I understand I or my dependent is receiving online Services from the Medical Group, and, unless the only Service purchased is the Snapshot, 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 or Snapshot on behalf of a dependent, I confirm that I have the legal right to consent on behalf of 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, 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.
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.
Patient No-Show Policy and Charge Notice
We ask patients to reschedule appointments at least 24 hours in advance if unable to attend.
A $50 no-show fee will be charged if a patient arrives more than 10 minutes late for an initial appointment or more than 7 minutes late for a follow-up.
However, this fee is waived if the patient is on time but the provider is not present.
Refund Policy
All refund requests must be reviewed and approved by the ADHD Online team. Discharged patients are not eligible for a refund.
Once payment has been submitted and access to the assessment has been granted, even if you change your mind and choose not to finish the assessment, all purchases made through adhdonline.com are final and non-refundable except as prohibited by applicable law. You will not receive a refund if you or your dependent’s assessment do not receive the diagnosis you were expecting.
This policy applies regardless of whether an assessment, medical treatment or therapy services are utilized. You may stop care with us at any time, return, and use the original assessment. Assessments are available in all 50 states. Medical Treatment is available in these states, and therapy is available in these states where we offer these services. Assessments can be used with one of our providers if you or your dependent lives in a state where we offer treatment or the assessment can be taken to your provider. Assessments are accepted by most clinicians in all 50 states. It is the patient’s responsibility to confirm the availability of preferred treatment in their state prior to purchasing the assessment.
In a payment dispute, the patient agrees to submit a ticket before taking any further action or requesting additional services.
adhdonline.com reserves the right to issue refunds or credits at our sole discretion. If a refund or credit is issued in one instance, we are under no obligation to issue the same refund or credit in the future. The ADHD Online team will review whether a refund request will be considered.
By using our services, you agree to the terms of this refund policy.
