Charges for Uninsured Services (NOT COVERED BY OHIP ...

1 TYPE OF SERVIC EDESCRIPTION OF Uninsured FORM/REPORT/SERVIC EFEESc hools/Camps$28. 50 Admis sion to Day-Care , P re school, U nivers it y or a ny other educational institution$28. 50 Pre -employment Certification of Fitness/Fitness Clubs$38. 25 hospital /Nursing Home E mployees$38. 25 Drivers Medical Examination$ Civil Aviation Medical Examination ReportPhysic ia n hourly ra tePil ots L ic ense ValidationPhysic ia n hourly ra teBack to Work Notes/Sick Notes$20. 00 Day C are N ote (f re e of communicable d is ease)$20. 00 OCF- 18 T reatment Pla n$ OCF- 3 Disability Certificate$ OCF- 19 Dete rmination of C ata strophic Impairment$ OCF- 23 Tre atment Confirmation$ Tra vel Cancell ation Insur ance Form$39.

2 00 Life I nsur ance Death Certificate$48. 75 Medical Certificate f or Employment Insur ance C ompassionate C are Benefit s$56. 00 Attending P hysic ia n s State ment$ Syste m Specific or Disease Specific Q uestionnaire$97. 00 Insur ance Medical Examination$ Syste m-Specific E xamination$ Full Narr ative/Cla rification Report$ Disability Medical Report Form(up to) $ 85 CPP The N arr ative Medical Report( u p to) $ 150 Revenue C anada, Federa l Disability Tax C re dit$75. 00 Children s Aid Soci ety Application for Prospective Foste r Parent$59. 00 Medical Certificate E mployment Insur ance Sickness Benefit s$40. 00 TB Test requeste d by Ministry of H ealt h Progra m ( P ublic H ealt h)OHIP covere dTB Test requeste d for admis sion or continuation in a d ay care , p re -school, school, college, u nivers it y or other educational institution.

3 T B Test I nsur ed by O HIP. C harg e f or Form/Report CompletionOHIP covere dOne Step TB Test$59. 12 Two Step TB Test$68. 10 Application for Accessible P ark ing Permit /T ra nsit Forms f or DisabledPR Card Forms/Request f or Birth Certificate Form/Canadian Passport ApplicationChildren s Aid Soci ety Form (on behalf of a child)/Ministry of H ealt h and Long-Term Care ( L imit ed Use, Assistive Devic es e tc .)Copies f rom the Patient s C hart (up to 20 pages)$ of the Full C hart (over 20 p ages). $ + $ .25 p er page f or each page over 20 p ages.$30. 00 + $ 0. 25 onto a CD(up to) $ 60 Letter for massage thera py, orthotics , b ack support, stockings e tc .$30. 00 Mis sed Appointment$40.

4 00 Mis sed Period Healt h Exam$75. 00 Mis sed Speci ali st Appointment$ Non-Resident Vis it Fee OMA RatePre -op Assessment ( by Genera l Pra ctitioner)$ -op Assessment ( b y Speci ali st)$77. 17 Lost Requisition/Referr al$ Fax P re scription Refil l$15. 00 Tra vel Advic e a nd Vacc ine Administration (must be p ur chased from P harmacy)$65. 00 PAP T est**Charg e f or PAP T est by P hysic ia n$42. 27 Ear s yringing**Ear Syringing $25. 99 Ear Wax Debr idementWax Debr idement by the O tolary ngologist $50. 00 Ont ario Medical Ass ociation (OMA) Guidelines Ja n to Dec 2020 Charg es fo r Uninsure d Serv ic es (NOT COVERED BY OHI P) Unremunerat ed Report Forms: (Physi cian i s NOT p ermitted to charge a patient f or compl etion)No Charg eChart Copies:Insur ance Certificat es: (Note: An as se ss ment f ee c an b e charged in addition to t he insur ance form f ee i f a n as se ss ment i s necessar y t o obt ai n relevant i nf ormation needed to c ompl ete t he f orm)Compl etion of Form P hysi cal s for:Compl etion of L icensing Forms/Certificat es:Compl etion of Work a nd School Relat ed Forms/Notes:Other Certificat es.

5 TB Mantoux Testing** MAYBE C OVERED B Y OHIP IF C ERTAIN CRITERIA ARE METO ther.