FEE FOR UNINSURED SERVICES

Without OHIP

• Expired Health Card or Non-Resident Visit Fee (9am-3pm), $60.00
• Expired Health Card orNon-Resident Visit Fee (after 5pm and weekend), $70.00

Completion of Form Physicals and Forms (may need multiple visits for walk-in patients):

• Schools/Camps, $50.00
• Admission to Day-Care, Preschool, University or any other educational institution, $50.00
• Pre-employment Certification of Fitness/Fitness Clubs, $50.00
• Hospital/Nursing Home Employees, $50.00
• Pregnancy Test without OHIP (only doctor will read results), $30.00
• Student disability verification form for enrolled patients, $100.00

Completion of Licensing Forms/Certificates:

• Drivers Medical Examination, $160.00
• Civil Aviation Medical Examination Report, $160.00/hr
• Pilots License Validation, $160.00/hr

Completion of Work and School Related Forms/Notes:

• Back to Work Notes/Sick Notes, $30.00
• University Specific Sick Note, $40.00
• Peel District School Board Attending Physician Statement (APS #001), $60.00
• Halton District School Board, Abilities Form, $60.00
• Immunization Record Update and Completion of Forms for Work/School, $50.00

Insurance Certificates:

Note: An $100.00 assessment fee can be charged in addition to the insurance form fee if an assessment is necessary to obtain relevant information needed to complete the form.

• OCF-18 Treatment Plan, $150.00
• OCF-3 Disability Certificate, $150.00
• OCF-19 Determination of Catastrophic Impairment, $120.00
• OCF-23 Treatment Confirmation, $145.00
• Travel Cancellation Insurance Form, $50.00
• Life Insurance Death Certificate, $60.00
• Short Medical Certificate for Employment Insurance Compassionate Care Benefits, $60.00
• Long Medical Certificate for Employment Insurance Compassionate Care Benefits, $100.00
• Attending Physician’s Statement, $150.00
• System – Specific or Disease Specific Questionnaire, $100.00
• Insurance Medical Examination, $250.00
• System-Specific Examination, $120.00
• Full Narrative/Clarification Report, $400.00/hr.

Government Forms (only for Enrolled patients):

• Medical Report for Canada Pension Plan Disability Benefits (bill to Service Canada for $85.00)
• Revenue Canada, Federal Disability Tax Credit, $75.00
• Children’s Aid Society Application for Prospective Foster Parent, $60.00
• Jury Duty Letter, $30.00
• Medical Certificate Employment Insurance Sickness Benefits, one page, $40.00
• Medical Certificate Employment Insurance Sickness Benefits, two or more pages, $80.00

TB Mantoux Testing:

• TB Test requested by Ministry of Health Program (e.g. Public Health), FREE
• TB Test requested for student only, admission or continuation in a day care, pre-school, school, college, university or other educational institution is FREE
• If Form/Completion report needs to be filled out, $40.00
• One Step TB Test for work, $20.00 for injection, $20.00 for read (Total $40 for one step test)
• Two Step TB Test for work, $20.00 for injection, $20.00 for read, $20.00 for 2nd injection, $20.00 for second read (Total $80 for two step test)
• If Form/Completion report needs to be filled out, $40.00

Paps:

• If requested earlier than 3 years as per OHIP covered limit, $60.00

Ear Syringing and Wart Procedure:

• Ear cleaning, $30/ear
• Each wart-cryotherapy, $30/ear
• Wart-cryotherapy on foot, FREE

Unremunerated Report Forms:

Physicians will NOT charge a patient for completion

• Application for Accessible Parking Permit/Transit Forms for Disabled
• PR Card Forms/Request for Birth Certificate Form/Canadian Passport Application.
• Children’s Aid Society Form (on behalf of a child)/Ministry of Health and Long-Term Care (e.g. Limited Use, Assistive Devices etc)

Chart Copies:

• Copies from the Patient’s Chart (up to 20 pages), $1.00/pg.
• Transfer/Copy of the Full Medical Chart to another medical clinic, $100.00

Without OHIP:

• For NO OHIP patients, letter/referral/Rx for massage therapy, orthotics, back support, stockings etc., $30.00
• Pre-op Assessment, $150.00
• Adult physical, $150.00
• Lost Reqisition/Referal, $25.00

TRAVEL MEDICATION (One or Multiple):

• Administered injection for (HEP A, HEP B, Twinrix, HPV/Gardisil, Menactra, Zostavax/Shingles, Thyphrix, Avaxim), $15.00/each injection.
• Travel Advice/Consultation for first family member, $60.00
• Travel Advice/Consultation for EACH other family members, FREE
• Travel Prescription for first family member, $30.00
• Travel Prescription for EACH other family member, $25.00
• Travel Cancellation Insurance Form, $50.00

Physical for Visa application:

• Physical for Visa requirement for enrolled patients, $100.00
• Physical for Visa requirement for non-enrolled patients (may require multiple visits), $150.00