ADHD Online, LLC
Terms & Patient consent
PATIENT CONSENT, RELEASE OF LIABILITY, AND USER AGREEMENT
I HEREBY CONSENT to the following terms and conditions respective of the services that may be be provided to me, or the patient of which I attest to be the legal guardian, by ADHD Online, LLC (“ADO”).
The services include completion of an online asynchronous E-visit assessment for ADHD (“Assessment”), which will be reviewed and interpreted by a psychologist or physician (“Provider”) deemed by ADO to be a qualified expert in the field of ADHD; plus additional services including but not limited to psychological counseling, medication management, and coaching. In consenting to, and agreeing to pay for these services, I understand, knowingly, and willingly accept the following terms and conditions.
1) Legal Medical Record
- I understand I or my child is receiving online services by a provider, and a legal medical record of the event will be created.
- I understand the services are strictly confidential and protected by HIPAA privacy laws.
- I attest that the name and health information I provide is true to the best of my knowledge.
- If completing an Assessment on behalf of a child or dependent, I certify that I have the legal right to consent to a medical evaluation for that person.
- I attest that I or the person for whom I am completing an assessment are/is currently present in the state I select for the Assessment.
- I can request a copy of my 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.
- ADO will complete and provide to me electronically an ADHD diagnosis and assessment for myself or my child based on the ADO questionnaire completed by me online.
- I understand that the assessment will be the sole basis for the evaluation of ADHD.
- I 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 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 child will be diagnosed with ADHD and that professional fees paid are for an assessment for ADHD, not a diagnosis.
- Most Assessments are completed in 1-5 business days, but I understand that extenuating circumstances may delay the completion of my or my child’s Assessment and that a delay in processing the Assessment is not grounds for a refund.
- By signing up for an account with ADO, I consent to allowing 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, 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 ADHD and its affiliates. Emails, calls, or SMS text messages will identify ADO or ADHD Online but will not contain additional private health information such as diagnosis or treatment information, unless I specifically authorize.
- 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 allowing ADO to respond with that information.
3) 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.
4) Monthly Payment Option for ADHD Assessment:
- If I choose to pay for an ADHD Assessment using the monthly payment option, I am opening a line of credit with ADO in the amount of $110 for the sole purpose of financing an Assessment.
- ADO will not complete a credit check as part of the approval process.
- ADO will charge an interest rate of 0%.
- I agree to make 3 monthly payments as follows:
- I will be charged $55.00 to begin the Assessment (“First Payment”)
- I will be charged $55.00 30 days after the First Payment is made (“Second Payment”)
- I will be charged $55.00 60 days after the First Payment is made (“Third Payment”)
- I understand I will be charged a one-time $25 late fee for each late payment.
- I give ADO permission to charge my credit card on file on a daily basis until any outstanding balance is paid.
- I agree to pay invoices sent to me by ADO for outstanding balances.
- Enrollment in the monthly payment option will not delay my or my child’s assessment from being completed.
5) 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 child 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.
6) Collections Policy:
- Unpaid fees, including charge-backs, will be forwarded to a collection agency.
- Credit card chargebacks, as ADO deems frivolous, 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 understand I will have the opportunity to download a copy of my patient privacy rights.
THEREFORE: 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 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.