Terms of Service
These terms of service in the following paragraphs (the “Terms”) define the obligations of AGM HEALTH, LLC (“AGM HEALTH”) and its authorized agents, and me, as a patient, and establish the basic rules this patient mental health information program and patient mental health information questionnaire (the “Survey”). AGM HEALTH and its authorized agents reserve the right to immediately and without advance notice deny access to individuals who do not abide by the Terms.
Use of Patient Mental Health Questionnaire
AGM HEALTH will furnish the Survey to me prior to my visit with a healthcare professional today. It is my duty to be truthful and accurate with all the information I enter into the Survey and not doing so will result in less effective care. I understand that my results will be provided to me and other healthcare professionals for purposes of assessing my emotional and situational well-being and if necessary, options for mental health counseling may be provided to me.
Release of Information
I authorize the release of necessary information, including the results of the Survey, to healthcare professionals. Authorization is hereby granted to release my protected health information (as defined in the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”)), including copies of the results of the Survey, to my primary care, attending and/or admitting healthcare professional and/or consulting healthcare professional, and/or any healthcare professional I may be referred to for follow up care. I authorize AGM HEALTH to disclose certain minimal necessary information about me (including my name, date of birth, email address and telephone number) to a healthcare professional for the purpose of referring me to a mental health professional, to the extent that my answers to the Survey indicate this may be beneficial to my health and well-being. I understand that this authorization for the use and disclosure of my protected health information does not have an expiration date and shall be valid until I revise or revoke this authorization. I understand that I may revoke this authorization by giving written notice at any time to AGM HEALTH, except to the extent that action has been taken in reliance on this authorization. I understand that I may refuse to make this authorization and AGM HEALTH may not condition treatment on whether I make this authorization.
Messages and Other Communications
I understand that based on the answers to the Survey AGM HEALTH, mental health professionals to whom I am referred, or staff may send messages to the telephone number or e-mail I have provided. These messages may contain information that is important to my health and medical care. It is my responsibility to monitor these messages. By entering my valid and functional e-mail address and telephone number, I have enabled AGM HEALTH to notify me of such messages. I agree not to hold AGM HEALTH or its authorized vendors and agents liable for any loss, injury or claims of any kind resulting from AGM HEALTH messages that I fail to read in a timely manner.
I understand and acknowledge that if I indicate thoughts of self-harm in the Survey, a behavioral provider will call me at the telephone number I provided to provide support which may result in a co-payment and my insurance being billed.
Disclaimer
I understand that AGM HEALTH, its owners, directors, officers, providers, agents, employees, contractors, subsidiaries, successors, and assigns (the “AGM Health Parties”) take no responsibility for and disclaim any and all liability arising from any action, inaction, omissions, negligence, inaccuracies or defects in any items or services furnished by any third parties, including but not limited to all computers and other digital equipment, internet connectivity, and software used to run the Survey; and I shall indemnify, hold harmless, and waive all claims against AGM HEALTH from and in connection with the same. I understand that the mental health support services rendered by AGM HEALTH are subject to the discretion and professional judgment of AGM HEALTH and any mental health professionals to whom I may be referred.
General Terms
If any provision or provisions in these Terms shall be held to be invalid, illegal or unenforceable, the validity, legality and enforceability of the remaining provisions shall not be affected thereby. It is understood that no delay or omission in exercising any right or remedy identified herein shall constitute a waiver of such right or remedy, and shall not be construed as a bar to or a waiver of any such right or remedy on any other occasion. Any litigation or other claims arising out of these Terms or the Survey furnished by AGM HEALTH shall be mediated, arbitrated, litigated, or otherwise heard in Miami-Dade County, Florida, including the federal and state courts located therein, and the laws of the State of Florida shall apply.
I understand by clicking below and signing this form, I agree to this TERMS OF SERVICE. I am electronically signing this form.