Uninsured Services
Uninsured services are not covered by OHIP. The patient is responsible for payment of these services rendered. Please check if your workplace will reimburse you for completion of these forms. If you have additional health benefits, you may check to see if these services are covered under your extended benefits.
The fees listed below include the cost of assessment, chart review, completion of form and mailing or long-distance fax charges, if applicable.
Please be advised that the physicians reserve the right to waive or make adjustments to the prices listed below.
Workplace Forms
$25.00
EMR Note for work/allied health services
$25.00
$35.00
Workplace Form for work (1 page)
$35.00
$55.00
Workplace Form for work (+2 pages)
$55.00
$55.00
Workplace FAF (not WSIB)
$55.00
Insurance and Disability Forms
$25
Note for Insurance
For coverage of physiotherapy, massage therapy, orthotics or compression stockings
$25
$35.00
CPP Disability Forms
$35.00
$55.00
CRA Disability Tax Credit
$55.00
$45.00
Insurance APS (1 page)
$45.00
$55.00
Insurance APS (2 page)
$55.00
Ministry of Transport Forms
$165.00
MOT Driver's Medical/ Non-OHIP Physical (18 years and over)
$165.00
$50.00
MOT Reinstatement Form/Follow up Form
$50.00
Medical Records Transfer
The fee includes cost of chart review, printing and mailing or long-distance fax charges if applicable.
$5.00
Test Result Copy (less than 5 pages)
$5.00
$10.00
Test Result Copy (greater than 10 pages)
$10.00
$50.00
Medical Records Transfer (less than 100 pages)
$50.00
$75.00
Medical Records Transfer (greater than 100 pages)
$75.00
Other
$50.00
Non-OHIP Child’s Physical (under 17 years old)
$50.00
$50.00
School Immunization Screening Forms (University Admission)
$50.00
$40.00
TB Screening – Work – 1 Step
$40.00
$50.00
TB Screening – 2 Step
$50.00
$65.00
Travel Vaccine - 1st Visit and 1st Injection
$65.00
$10.00
Subsequent Injections
$10.00
$35.00
Travel Cancellation Form
$35.00
$55.00
Travel Cancellation Form (+2 page)
$55.00
$25.00
Out of Province Patients Flu Shot
$25.00
$45.00
Citizenship and Immigration Report
$45.00
$45.00
Adoption/Foster Parent Forms
$45.00
$75.00
Retirement Residence Admission Forms
$75.00
Procedures
$15.00
Liquid nitrogen for 1 hand warts/benign lesions
$15.00
$25.00
Liquid Nitrogen for 2 or more hand warts/benign lesions
$25.00
$100.00
Cosmetic mole or skin tag removal
$100.00
$25.00
Tray fee for malignant skin biopsy
$25.00
$40.00
IUD Insertion Tray Fee
$40.00
Missed Appointments:
For no shows to appointments.
$30.00
15-minute appointment
$30.00
$60.00
30-minute appointment
$60.00
$100.00
Missed Physical Appointment
$100.00