LIGHTHOUSE EVALUATION SERVICES, PLLC

TERMS & CONDITIONS

Updated 4/16/2024

I HEREBY CONSENT to the following terms and conditions related to the services that may be provided to me, or the individual for whom I represent and warrant I am the legal guardian, by Lighthouse Evaluation Services, PLLC.

I attest that I and/or my child/dependent are present in Florida or Another PSYPACT state/territory within the United States for the evaluation. 

LIGHTHOUSE EVALUATION SERVICES, PLLC IS LOCATED IN FLORIDA. All disputes, if any, arising from the telehealth service(s) will be resolved in Florida, and Florida law will govern any such disputes. 

LIGHTHOUSE EVALUATION SERVICES, PLLC provides services to states that participate in PSYPACT.

PSYPACT is an interstate compact which offers a voluntary expedited pathway for practice to qualified psychologists who wish to practice in multiple states. PSYPACT is designed to facilitate the practice of telepsychology and the temporary in-person, face-to-face practice of psychology across state boundaries.  In order to practice telepsychology in PSYPACT states, psychologists licensed in PSYPACT states only, can apply to the PSYPACT Commission for an Authority to Practice Interjurisdictional Telepsychology (APIT).  In order to conduct temporary practice in PSYPACT states, psychologists licensed in PSYPACT states only can apply to the PSYPACT Commission for a Temporary Authorization to Practice (TAP).  The PSYPACT Commission is the governing body of PSYPACT and is comprised of one representative from each PSYPACT state. More information regarding PSYPACT and its requirements can be found at www.psypact.org. 

DR. JOHN BLAZE has met all requirements and has obtained an Authority to Practice Interjurisdictional Telepsychology (APIT) from the PSYPACT Commission. By obtaining this authorization, this serves to show that they have met all requirements to be eligible to provide interjurisdictional services under the authority of PSYPACT. APIT Number: 10085 APIT Issue Date: 08/04/2023.

PSYPACT® PARTICIPATING STATES (42 ENACTED, 42 EFFECTIVE)

Alabama - AL SB 102 (Enacted 3/18/2021; Effective 6/1/2021)

Arizona - AZ HB 2503 (Enacted on 5/17/2016; Effective 7/1/2020)

Arkansas - AR HB 1760 (Enacted 4/25/2021; Effective (11/18/2021)

Colorado - CO HB 1017 (Enacted 4/12/2018; Effective 7/1/2020)

Commonwealth of the Northern Mariana Islands - CNMI HB 22-80 (Enacted and Effective 10/24/2022)

Connecticut -CT S 2(Enacted 5/24/2022; Effective 10/1/2022)

Delaware - DE HB 172 (Enacted 6/27/2019; Effective 7/1/2020)

District of Columbia - DC B 145 (Enacted and Effective 4/2/2021)

Florida -FL H 33(Enacted 5/25/2023; Effective 7/1/2023)

Georgia - GA HB 26 (Enacted 4/23/2019; Effective 7/1/2020)

Idaho - ID S 1305 (Enacted 3/23/2022; Effective 7/1/2022)

Illinois - IL HB 1853 (Enacted 8/22/2018, Effective 7/1/2020)

Indiana -IN S 365(Enacted 3/10/2022; Effective 7/1/2022)

Kansas - KS SB 170 (Enacted 5/17/2021; Effective 1/1/2022)

Kentucky - KY HB 38 (Enacted 3/18/2021; Effective 6/28/2021)

Maine - ME HB 631 (Enacted 6/22/2021; Effective 10/18/2021)

Maryland - MD HB 970 (Enacted and Effective 5/18/2021)

Michigan -MI H 5489(Enacted 12/22/2022; Effective 3/29/2023)

Minnesota - MN SB 193 (Enacted 5/25/2021; Effective 5/26/2021)

Mississippi -SB 2157 (Enacted 4/8/2024; Effective 4/15/2024)

Missouri - MO HB 1719/MO SB 660 (Enacted 6/1/2018; Effective 7/1/2020)

Nebraska - NE L 1034 (Enacted 4/23/2018; Effective 7/1/2020)

Nevada - NV AB 429 (Enacted on 5/26/2017; Effective 7/1/2020)

New Hampshire- NH SB 232 (Enacted 7/10/2019; Effective 7/1/2020)

New Jersey -NJ A 4205(Enacted 9/24/2021; Effective 11/23/2021)

North Carolina - NC 361 (Enacted 7/1/2020; Effective 3/1/2021)

North Dakota - ND S 2205  (Enacted 4/13/2023; Effective 8/1/2023)

Ohio -OH S 2 (Enacted 4/27/2021; Effective 7/26/2021)

Oklahoma - OK HB 1057 (Enacted 4/29/2019; Effective 7/1/2020)

Pennsylvania- PA SB 67(Enacted 5/8/2020; Effective 7/8/2020)

Rhode Island -RI H 7501(Enacted 6/21/2022; Effective7/1/2023)

South Carolina -SC H 3204(Enacted 5/16/2023; Effective7/17/2023)

Tennessee -TN S 161 (Enacted and Effective 5/11/2021)

Texas - TX HB 1501 (Enacted 6/10/2019; Effective 7/1/2020)

Utah - UT SB 106 (Enacted on 3/17/2017; Effective 7/1/2020)

Virginia- VA SB 760(Enacted 4/11/2020; Effective 1/1/2021)

Washington -WA H 1286(Enacted 3/4/2022; Effective 6/9/2022)

West Virginia - WV SB 668 (Enacted 4/21/2021; Effective 11/18/2021)

Wisconsin -WI A 537 (Enacted 2/4/2022; Effective 2/6/2022)

Wyoming - WY S 26 (Enacted 2/15/2023; Effective 2/15/2023) 

South Dakota - SD H 1017 (Enacted 2/13/24: Effective 7/1/2024)

Vermont - VT H 282  (Enacted 6/1/2023; Effective  7/1/2024)

The services include completion of an online evaluation for (a) FL homeschooling annual review evaluation, which includes a permanent product review with online interview by a licensed psychologist using doxy.me or (b) an online diagnostic mental health disorder evaluation with mental status exam by a licensed psychologist using doxy.me. Remote evaluation sessions shall not be recorded by either party, in any way.

For homeschooling evaluations, I understand that I alone will receive the evaluation results and that it is my responsibility to supply it to my student's school district, as the law requires. I do authorize Lighthouse Evaluation Services, PLLC and/or psychologists to release evaluation results, including a form with a summary of the evaluation results to my child/dependent's local Home Education District Contact as noted in https://www.fldoe.org/schools/school-choice/other-school-choice-options/home-edu/district-home-edu-contacts.stml and/or http://www.floridaschoolchoice.org/Information/District/district_list.asp?prgmtype=4 as needed or in special circumstances.

I understand that for an evaluation, Lighthouse Evaluation Services, PLLC will facilitate the collection of my or my child’s (or legal dependent) information including, but not limited to, relevant academic, social, medical, mental health and behavioral data. The type of data collected with depend on the type of evaluation. In consenting to, and agreeing to pay for these services, I understand, knowingly, and willingly accept the terms and conditions of this document.

I understand the services are strictly confidential and protected by applicable privacy laws. I confirm that the name and information I provide is true to the best of my knowledge. If initiating and/or completing an evaluation on behalf of a dependent, I confirm that I have the legal right to consent to an evaluation for that individual.

I understand that Lighthouse Evaluation Services, PLLC does not guarantee that I or my dependent will be diagnosed with a mental health condition and that fees paid are exclusively for an evaluation for homeschooling progress or mental health conditions. I understand there will be no refunds once the evaluations are initiated, even if I change my mind and choose not to finish the evaluation with Lighthouse Evaluation Services, PLLC. Furthermore, refunds will not be issued if the results of the evaluation or diagnosis received differs from what I was expecting. I understand that diagnostic evaluations may take several days to a week, depending on the clinical complexity. Therefore, any delays I experience in obtaining the results are not grounds for a refund. 

Contacting by phone, SMS text, sending an email, paying for an evaluation, or otherwise contacting regarding services through social networking websites with Lighthouse Evaluation Services, PLLC, I consent to allowing Lighthouse Evaluation Services, PLLC to communicate with me about my evaluation needs via phone, SMS text, social networking (e.g., Facebook), or email.  If I send an email, phone call, electronic communication, or SMS text message to Lighthouse Evaluation Services, PLLC requesting disclosure of private health information (PHI) such as diagnosis or evaluation results, I consent to allowing Lighthouse Evaluation Services, PLLC to respond with that information via SMS text message, email, or other electronic means. I understand and accept the risks associated with sending PHI electronically.

This Agreement shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable Florida law. I HEREBY ACCEPT ANY AND ALL RISK related to the services Lighthouse Evaluation Services, PLLC provides and/or have been provided to me by Lighthouse Evaluation Services, PLLC.

I understand Lighthouse Evaluation Services, PLLC does not provide any treatment and that participating in an evaluation is voluntary. I understand participating in an evaluation does not constitute a therapeutic relationship. I INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE Lighthouse Evaluation Services, PLLC or psychologists mentioned in this document from any and all liabilities or claims made as a result of participation in a homeschool evaluation or diagnostic evaluation, whether caused by negligence or otherwise.

I understand that I should never use Lighthouse Evaluation Services, PLLC in an emergency. I understand that in an emergency, I should dial 911 or go to an emergency department. I understand that the electronic nature of the evaluations poses a greater privacy risk than in-person evaluations. I understand that although Lighthouse Evaluation Services, PLLC will make reasonable effort to ensure my PHI is protected, Lighthouse Evaluation Services, PLLC cannot 100% guarantee the privacy and confidentiality of data collected.

I understand that remote psychological services involves the delivery of evaluation services using electronic communications from cell phone or computers, information technology, and other means between a psychologist and an individual who are not in the same physical location. I understand that psychologists have no way of verifying the information I provide is accurate, true, and complete. Therefore, evaluations provided by Lighthouse Evaluation Services, PLLC should not be used for custody disputes or other family law issue.

 There are rare occasions in which privacy and confidentiality must be suspended and, in which cases, information will be reported to the local authorities: These include (a) when there is a reasonable basis to believe that a participant may be involved in serious child abuse, abuse of the elderly, or abuse of any individuals who are deemed unable to protect themselves, (b) when psychologists are court-ordered to provide to release information, and (c) when there is a reasonable basis to believe that a participant or individual poses a serious risk to themselves or others, as noted in Florida as noted in Chapter 394 of the Florida Statutes.

FINANCIAL POLICY 

1.  PAYMENT is expected at the time your evaluation begins, when you, the client, initiate the evaluation. Lighthouse Evaluation Services, PLLC will accept credit card via Square. Payment in full is expected and partial or delayed payment is not an option.

2.  INSURANCE is not accepted by Lighthouse Evaluation Services, PLLC , nor Medicaid or Medicare. We do not participate in any insurance networks, nor will Lighthouse Evaluation Services, PLLC file any or process claims for you. You are 100% self-pay. However, you may reach out to your insurance company or HSA provider to submit your paperwork for partial reimburse on your own accord. We do accept HSA and FSA debit cards.

3.  LATE CHARGES of 12% annually will be applied to all patient balances 90 days old or greater.

4.  ACCOUNTING PRINCIPALS - Payment and credits are applied to the oldest charges first.

5.  FORMS FEES require time and time away from client care. We require pre-payment for completing forms, copying medical records, or for extra written communication by the Psychologist. The charge is determined by the complexity of the form, letter, or communication. Base form charges are $10 per occurrence plus and applicable postage or notary fees. Postage is additional and payment is required in advance. Copying fees for Medical Records is $25 for the first twenty (20) pages and $0.75 per page in excess of twenty.

6.  CANCELLATIONS OR MISSED APPOINTMENTS are not grounds for a refund. Full payment is expected and non-refundable unless the evaluation has not begun, that is, there have been no actions taken by the Psychologist to prepare for your evaluation. Errors or mistaken payments will be refunded under the same terms.

7.  RESPONSIBILITY FOR PAYMENT: I understand that I, personally, am financially responsible to Lighthouse Evaluation Services for all charges.  

8.  COLLECTION FEES: I understand that in the event my account is placed in collection status, any additional fees incurred due to this, will be added to my outstanding balance. This includes but is not limited to late fees, collections agency fees, court costs, interest and fines.   I understand that these additional fees will be my personal responsibility to pay in full.

9.  DIVORCED PARENTS of CLIENTS: By initiating an evaluation, making a payment, or signing a consent form, the adult who signs a minor child in on the day of service accepts responsibility for payment. This office does not promise to send bills or records to the other parent/guardian for issues of payment or communication. We will communicate about evaluation services and payment with the parent who signs in that day. Parents are responsible between themselves to communicate with each other about the evaluation and payment issues. 

No Surprises Act 

Effective January 1, 2022, the No Surprises Act, which Congress passed as part of the Consolidated Appropriations Act of 2021, is designed to protect patients from surprise bills for emergency services at out-of-network facilities or for out-of-network providers at in-network facilities, holding them liable only for in-network cost-sharing amounts. The No Surprises Act also enables uninsured patients to receive a good faith estimate of the cost of care.

Billing Disclosures – Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care–like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have the following protections:

• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.

• Your health plan generally must:

  • Cover emergency services without requiring you to get approval for services in advance (prior authorization).

  • Cover emergency services by out-of-network providers.

  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.

  • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact:

• The U.S. Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE (1-800-633-4227) or visit https://www.cms.gov/nosurprises for more information about your rights under federal law.

Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

Under the law, healthcare providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment and hospital fees.

• Make sure your healthcare provider gives you a Good Faith Estimate in writing at least one business day before your medical service or item. You can also ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

• Make sure to save a copy or picture of your Good Faith Estimate.

Get More Information

For questions or more information about your right to a Good Faith Estimate, visit cms.gov/nosurprises or call 1-800-MEDICARE (1-800-633-4227).

Good Faith Estimates for Health Care Items & Services

For ALL HOMESCHOOL EVALUATIONS:

For ALL DIAGNOSTIC EVALUATIONS:

I have read and understand the practice’s financial policy and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice from time to time. I understand that Lighthouse Evaluation Services, PLLC does not take any type of health and/or medical insurance, which includes Medicaid and/or Medicare. Therefore, all services are self-pay and I understand that payment is due at the time of service. I further agree to pay invoices sent to me by Lighthouse Evaluation Services, PLLC. Refunds will not be issued once the evaluation process has started. If a refund is requested prior to any evaluation activities beginning, including but not limited to any preparation work on Lighthouse Evaluation Services, PLLC's part to prepare for such evaluation, then the refund will be issued in full. Please call Lighthouse Evaluation Services, PLLC or email if payment was made in error and we will be happy to refund you. Secure payments are handled exclusively through Square.

I UNDERSTAND THAT I AM REQUIRED TO SIGN THE INFORMED CONSENT AND NOTICE OF HIPAA PRIVACY PRACTICES (https://signsafe.it/Lighthouse/InformedConsent) PRIOR TO ANY EVALUATION. I CERTIFY THAT I HAVE READ THIS DOCUMENT, AS WELL AS THESE TERMS & CONDITIONS AND PRIVACY POLICY, AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND THAT SUBMITTING PAYMENT AND/OR SIGNING THE ABOVE INFORMED CONSENT AND HIPAA NOTICE CONSTITUTES VOLUNTARILY SIGNING THE AGREEMENT OF MY OWN FREE WILL.