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 on whose behalf I am requesting the Services be performed. I represent and warrant that I have the capacity and authority to consent to these terms and conditions and agree that Mentavi can reasonably rely on my representation.
The Services
I understand these Terms and Conditions govern my 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, but are not limited to, a mental health Diagnostic Evaluation, sometimes called the Diagnostic Evaluation, an online wellness snapshot (a self-assessment tool) which is evaluated and scored through the use of a proprietary scoring systems, medical treatment services, cognitive behavioral therapy, counseling and therapy and mental health coaching (collectively the “Services”). I understand the Services will be provided by a doctorate-level psychologist, licensed physician, licensed advanced practice provider, licensed social worker or a mental health coach (“Provider”) authorized to practice in the state where I am located. The Snapshot is a self-assessment informational tool developed by the team providing the 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. 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 the Snapshot, neither I nor my dependent receive medical services from the Medical Group or Mentavi. I understand that Mentavi uses the Platform to facilitate the collection of personal history and information for the Snapshot. I understand that the Snapshot is a self-assessment informational tool, and is not diagnostic. 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 when completing the Snapshot no health care provider and patient relationship is created between me and Mentavi or the Medical Group. In consenting to, and agreeing to pay for these services, I understand, knowingly, and willingly accept these Terms and Conditions.
I understand that for a Diagnostic Evaluation, 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 Diagnostic Evaluation with a Provider. A portion of the Diagnostic Evaluation 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 these Terms and Conditions.
Legal Medical Record
I understand that when I or my dependent is receiving online Services from the Medical Group, 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 are true to the best of my knowledge. If requesting and paying for Services 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 is present in the state I select for the Diagnostic Evaluation.
I understand I can request a copy of my or my dependent’s records by submitting a signed release form on the Platform. I may request that Medical Groups correct health information that I feel is incorrect or incomplete. Should Medical Groups deny the request, an explanation will be within 60 days. I understand that I can review how the Medical Groups use my medical information by reviewing the Notice of Privacy Practices and the Privacy Policy.
I understand that the Diagnostic Evaluation will be the sole basis for the initial evaluation of mental health unless my Provider requests additional information. I understand that I 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 Diagnostic Evaluation. 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 the Medical Groups do not guarantee that I or my dependent will be diagnosed with ADHD or any other mental health conditions and that professional fees paid are exclusively for completion and review of the Diagnostic Evaluation. I understand that if a diagnosis is made, there will be additional fees related to medical treatment, medication management, counseling or other Services. Most Diagnostic Evaluations 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 Diagnostic Evaluation and that a delay in processing the Diagnostic Evaluation is not grounds for a refund.
Communication
By signing up for an account with the Platform, I consent to allow the Medical Groups and Mentavi to email, call, or SMS text me about my account. Such communication may include: requests to reset my password, account verification requests, notifications of portal messages or upcoming appointments, follow-up about services in which I have indicated interest or have purchased, or to follow up about additional mental health and wellness services offered by the Medical Groups and its affiliates.
I will have the opportunity to opt out of emails and SMS text messages at any time, and the Medical Groups 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 the Medical Groups requesting disclosure of private health information such as diagnosis or treatment information, I consent to allow the Medical Groups 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 the Medical Groups do not directly participate with health and/or medical insurance, including Medicaid and/or Medicare.
I understand that full payment is due at the time of service, unless I have taken advantage of the 3 installment payment plan available for the Diagnostic Evaluation, in which case part of the payment is due at the time of service. I understand other terms and conditions apply to the installment plan.
The Medical Groups or Mentavi will provide me with paperwork to submit to my insurance company for reimbursement. I understand the Medical Groups and Mentavi do not guarantee that my insurance company will provide reimbursement for any Services provided by or through the Medical Groups or Mentavi.
Diagnostic Evaluation Payment Plan Fees
If I choose our payment plan for the Diagnostic Evaluation, I understand my first payment of $69 will be processed right away. Then, I will be automatically charged $69 per month on the same date for the next two months. There will be no additional charges after the third payment. The total cost of the plan is $207, which includes an $18 administrative fee.
I understand I am not responsible for interest or finance charges in addition to the ones above. I understand that I can pay any balance at any time by calling or emailing the Medical Groups or Mentavi. I am responsible for late fees or returned payments charged by my credit card or banking institution.
Collections Policy
I understand that unpaid fees, including chargebacks, may be forwarded to a collection agency.
At the Medical Groups’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 the Medical Groups or Mentavi 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 the Medical Groups or Mentavi incur in such collection efforts.
Privacy Policy
The Medical Groups has a Privacy Policy and a Notice of Privacy Practices. I understand a link to each can be found on the Platform.
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 the Medical Groups and Mentavi have or will provide to me or my dependent.
I acknowledge and understand that this Agreement applies to the persons and/or entities to be used by the Medical Groups and Mentavi and their employees and/or independent contractors in providing the Services to me.
In consideration of my decision to hire these Services from the Medical Groups or Mentavi, 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, FOR ANY INCIDENTAL, INDIRECT, SPECIAL, EXEMPLARY AND CONSEQUENTIAL DAMAGES, PERSONAL OR BODILY INJURY, EMOTIONAL DISTRESS, OR WRONGFUL DEATH, LOSS OF DATA, LOST PROFITS, OR DAMAGES RESULTING FROM THE USE OF OR INABILITY TO USE THE SERVICE, INCLUDING ANY INFORMATION AND CONTENT MADE AVAILABLE THROUGH THE SERVICE OR ANY SERVICES PERFORMED OR PRODUCTS OFFERED BY THIRD PARTIES, WHETHER BASED ON WARRANTY, CONTRACT, TORT (INCLUDING NEGLIGENCE), OR ANY OTHER LEGAL THEORY, AND WHETHER OR NOT THE MEDICAL GROUPS AND MENTAVI HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. THE MEDICAL GROUPS AND MENTAVI SHALL BE LIABLE ONLY TO THE EXTENT OF ACTUAL DAMAGES INCURRED BY ME, NOT TO EXCEED U.S. $1,000.
ANY CLAIMS ARISING IN CONNECTION WITH MY USE OF THE SERVICE OR CONTENT MUST BE BROUGHT WITHIN ONE (1) YEAR OF THE DATE OF THE EVENT GIVING RISE TO SUCH ACTION OCCURRED.
SOME JURISDICTIONS DO NOT ALLOW THE EXCLUSION OF CERTAIN WARRANTIES OR THE LIMITATION OR EXCLUSION OF LIABILITY FOR INCIDENTAL OR CONSEQUENTIAL DAMAGES. TO THE EXTENT THAT THE MEDICAL GROUPS AND MENTAVI MAY NOT DISCLAIM ANY IMPLIED WARRANTY OR LIMIT THEIR LIABILITIES, THE SCOPE AND DURATION OF SUCH WARRANTY AND THE EXTENT OF THE MEDICAL GROUPS and MENTAVI’S LIABILITY WILL BE THE MINIMUM PERMITTED UNDER APPLICABLE LAW.
THE ABOVE WAVER OF LIABILITIES APPLIES TO THE FOLLOWING ENTITIES OR PERSONS:
Mentavi, the Medical Groups, their 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 the Services, whether caused by negligence or otherwise.
I acknowledge that the Medical Groups and Mentavi 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.
ARBITRATION AGREEMENT
IF YOU DO NOT AGREE WITH THESE TERMS AND CONDITIONS, DO NOT CREATE AN ACCOUNT OR USE THE SERVICES. YOU HEREBY GRANT AGENCY AUTHORITY TO ANY PARTY WHO CREATES AN ACCOUNT, USES THE SERVICES OR OTHERWISE INDICATES ACCEPTANCE TO THESE TERMS AND CONDITIONS ON YOUR BEHALF. UNLESS YOU TIMELY OPT-OUT OF ARBITRATION IN ACCORDANCE WITH THESE TERMS AND CONDITIONS, YOU AND WE AGREE THAT ALL DISPUTES BETWEEN YOU AND MENTAVI OR YOU AND THE MEDICAL GROUPS OR PROVIDERS ARISING OUT OF OR RELATED TO THESE TERMS AND CONDITIONS OR THE SERVICES, WILL BE RESOLVED BY BINDING AND FINAL ARBITRATION AND YOU AND WE WIAVE ALL RIGHTS TO A JURY TRIAL AND TO PARTICIPATE IN A CLASS ACTION LAWSUIT OR CLASS-WIDE ARBITRATION. IF YOU DO NOT WISH TO BE BOUND BY THIS ARBITRATION AGREEMENT, YOU CAN OPT OUT WITHIN THIRTY (30) DAYS AFTER FIRST BECOMING SUBJECT TO THIS ARBITRATION AGREEMENT. TO OPT OUT, YOU MUST SEND: 1) YOUR NAME; 2) RESIDENCE ADDRESS; 3) EMAIL ADDRESS; AND 4) A CLEAR STATEMENT THAT YOU WANT TO OPT OUT OF THE ARBITRATION AGREEMENT TO: MENATVI, INC., 625 KENMOOR AVE. SE GRAND RAPIDS, MI 49456, ATTN: ARBITRATION OPT-OUT (THE “OPT-OUT NOTICE”). YOU MUST SIGN THE OPT-OUT NOTICE FOR IT TO BE EFFECTIVE. ANY OPT-OUT NOTICE WILL BE EFFECTIVE ONLY IF YOU SENT IT YOURSELF, ON AN INDIVIDUAL BASIS, AND OPT-OUT NOTICES FROM ANY THIRD-PARTY PURPORTING TO ACT ON YOUR BEHALF WILL HAVE NOT EFFECT ON YOUR OR OUR RIGHTS. OPTING OUT OF THIS ARBITRATION AGREEMENT HAS NO EFFECT ON ANY PREVIOUS OR OTHER ARBITRATION AGREEMENTS THAT YOU CURRENTLY HAVE, OR MAY ENTER IN THE FUTURE, WITH US, THE MEDICAL GROUPS OR PROVIDERS. IF YOU OPT OUT OF THIS ARBITRATION AGREEMENT, ALL OTHER PARTS OF THESE TERMS AND CONDITIONS WILL CONTINUE TO APPLY TO YOU.
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 Mentavi. Discharged patients are not eligible for a refund.
Once payment has been submitted and access to the Diagnostic Evaluation has been granted, even if you change your mind and choose not to finish the Diagnostic Evaluation, all purchases made through the Platform are final and non-refundable except as prohibited by applicable law. You will not receive a refund if you or your dependent do not receive the diagnosis you were expecting or any diagnosis at all.
This policy applies regardless of whether a Diagnostic Evaluation, medical treatment, therapy services, coaching services or other Services are utilized. You may stop care at any time, return, and use the original Diagnostic Evaluation. Diagnostic Evaluations are available in all 50 states. Medical treatment, therapy and other Services are only available in certain states. It is your responsibility to confirm the availability of preferred treatment in their state prior to purchasing the Diagnostic Evaluation. You understand it is your responsibility to carefully review the website to understand what Services are available in your state. I understand that my failure to confirm a particular Service is not available in my state may not be grounds for a refund. Diagnostic Evaluations can be used with one of our providers if you or your dependent lives in a state where we offer other Services or the Diagnostic Evaluation can be taken to your local, in-person provider. Diagnostic Evaluations are accepted by most clinicians in all 50 states. Neither the Medical Groups nor Mentavi guarantee that the Diagnostic Evaluation will be accepted by any other providers or clinicians.
In a payment dispute, you agree to submit a ticket before taking any further action or requesting additional services.
The Platform 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 Platform will review whether a refund request will be considered.
I understand and agree that by using the Services, I agree to the terms of this refund policy.
