Insurance Information/Patient Agreement for Coverage

By providing the information above, I provide that I am the eligible member of this insurance plan. I am assigning my benefits to be paid directly to Dr. Dmitry Byk MD PA. I understand that I remain responsible for any and all payments for services rendered should my insurance fail to cover the charges.

Cancellation/Missed Appointment Policy

IMPORTANT DOCUMENT PLEASE READ

CANCELLATION / MISSED APPOINTMENT POLICY

Dr. Byk is committed to providing you with the most ethical and effective treatment possible. Therefore, he values every appointment that is scheduled and will reserve that date and time for you. This reservation, however, also preserves Dr. Byk’s time and precludes him from scheduling other clients. Therefore, if you are unable to attend your appointment, you may reschedule/cancel your appointment 24 hours prior to the time of your appointment online or you can call the office (Monday through Friday) during business hours. Self-pay patients who do not attend their scheduled appointment or do not cancel 24 hours before their appointment time will be charged the full amount of the appointment. Patients with insurance will be charged the full amount of their copay and the amount of the missed insurance payment. 

Thank you for your cooperation and understanding.

I have read and acknowledge the cancellation/missed appointment policy.

Coverage, After Hours, & Emergency Policy

IMPORTANT DOCUMENT PLEASE READ

COVERAGE, AFTER HOURS, & EMERGENCY POLICY

Dr. Byk sees patients during the following office hours: Tuesday through Thursday from 8:45am through 4:15pm. Phone calls are taken by staff and may be given to Dr. Byk during his regular office hours. Phone calls after these hours are answered by the service and will not be returned until regular business hours. The best way to contact Dr. Byk for questions about your appointment is via his email located on his website.

Please understand that this office does not handle emergency appointments or emergencies over the phone. If you have an emergency, please call 911 or go to a local emergency department.

Also, Dr. Byk does not have any physician coverage while he is away from the office. It is the sole responsibility of the patient to ensure that they have enough medication to make it to their next appointment. If you are prescribed medication and are running short due to missed appointments, because of scheduling appointments too far out, or other reasons, you can request refills during business hours. However, these requests may not be fulfilled. Please ensure that you speak with Dr. Byk about having enough medication to last until your next visit before you leave.

I have read and acknowledge the coverage, after hours, & emergency policy

Office Policy Notification, HIPAA, & Consent for Medication Retrievals

HIPAA Compliance: In accordance with the Health Insurance Portability and Privacy Act of 1996 which requires documented proof of acceptance of the office standards of privacy, this office provides all patients with a notice of the means of compliance with these HIPAA standards. According to the HIPAA laws, a patient can specify with whom their private medical information can be shared. It is the policy of this office that every patient must agree to allow this practice to share any necessary medical information with the following: the signed guarantor, patient's insurance company, third party administrator (insurance delegate), patient’s attorney and this practice's attorney (only if/when necessary). If you do not agree to these terms, you may elect to pay for all services rendered out of pocket and submit your claim independently or we will gladly refer you to another office for your medical services

Charges for Covered Benefits: Dmitry Byk, MD PA provides psychiatric services based solely on the belief in providing the finest patient care possible. As a result, at times these services may not be covered by certain insurance companies. The office will make all necessary attempts to recover reimbursement for these services directly from the insurance company. However, the patient is ultimately responsible for payment of services rendered. I understand and agree that I am responsible for charges for any services not covered by my insurance company when notified in advance that the services being provided are NOT covered. I further understand that I am responsible for any collection and/or attorney’s fees if non-payment of the account results in it being turned over to a collection agency or attorney.

I understand it is my responsibility to obtain all necessary authorizations in accordance with my insurance’s guidelines. I understand that my insurance does not guarantee payment regardless of authorization. Should my insurance deny payment, I am ultimately responsible for payment of services rendered. I understand and agree to make said payment upon notification either written or oral (at this office) – (N/A for out of pocket paying patients)

I understand that Dr. Byk only sees individual patients 18 years of age and older. Due to many changes in insurance policies, we cannot be responsible for interpreting each individual policy. It is your responsibility to know your individual coverage and its limitations, as well as who is a provider for your plan. We urge you to check with your insurance company regarding your benefits because failure to comply could result in you, the patient being responsible for all costs incurred. Please remember that your insurance policy is a contract between you and your insurance company. It is your responsibility to know to find out whether we are providers for your specific network. I am aware and hereby agree that I am responsible for any portion of my bill that is not paid or covered by me. If I change my insurance carrier, I understand that it is solely my responsibility to notify this office prior to any visit that would be under that insurance. I acknowledge that the practice does NOT balance-bill or charge for prescriptions and any charges are for services rendered under valid procedures recognized by the AMA and APA in accordance with Medicare.

I hereby authorize Dr. Byk to provide any necessary treatment. In the event I am prescribed medication, I am responsible for assuring I have enough medication and/or appropriate quantities until my next appointment. I understand that if I miss a certain number of appointments or are not seen for a certain length of time, Dr. Byk may require an appointment before a new refill can be authorized. I understand that this notice serves as an assignment of my benefits to Dr. Byk and this shall remain in effect until I provide further notice that I am paying for these services in full or I am no longer being treated by Dr. Byk.

When I schedule my appointment, I consent for Dr. Byk to perform a controlled substance search via the Electronic-Florida Online Reporting of Controlled Substances Evaluation (E-Force) website (florida.pmpaware.net I also consent for Dr. Byk to perform a medication reconciliation which involves retrieval of my medication history from my pharmacy.

Disclosure Statement

Dear Patient,

Please be advised that Dmitry Byk, MD PA is under the ownership of Dmitry Byk, MD. This location is also the office for The Center for Counseling of Aventura, Inc, which is under the ownership of Lori Grabois, MD and Lee Pravder, MD. The Center for Counseling of Aventura has psychiatrists, psychotherapists, and psychologists that are independent practitioners within this office. Please be aware that Dmitry Byk, MD PA and The Center for Counseling are independent entities and are not controlled, affiliated, or have any supervisory roles with one another. Also, neither of these entities are responsible for the billing of the other.

This letter is intended for information purposes only. If you have any questions regarding this, please feel free to speak with the office manager.

I certify that I have read this disclosure statement.