The following services are not covered by provincial health insurance and are billed directly to the patient.
Uninsured Service Fees
| Service | Fee |
|---|---|
| Doctor's note (NOTE) | $75 |
| Out of Country Visit (OCC) | $150 |
| Out of province/country phone appointment (PPA) | $50 |
| Chart transfer – digital copy (CHT1) | $50 |
| Chart transfer – paper copy (CHT2 + ADPG) | $50 for the first 20 pages + $0.50 per additional page |
| Wart treatment – initial (WART) | $75 |
| Re-printing of lost requisition (RPR) | $10 |
| Refill request without an appointment (FXRX) | $30 |
Form Fees
| Service | Fee |
|---|---|
| AISH Form (AISH) | $180 |
| Functional Abilities Form (FAF) | $100 |
| Drivers Medical Form – work related (DRM1) | $150 |
| Drivers Medical Form – 70+ / medically necessary (DRM2) | $120 |
| Attending Physician Statement (A002) | $200 |
| Short Term Disability Form (STD) | $80 |
| Long Term Disability Form (LTD) | $140 |
| Parking Placard Form (A013) | $70 |
| Disability Tax Credit Form (DTC) | $120 |
| Senior Residency Form (SRF) | $50 |
| Transit Access Form (TAF) | $80 |
| CPP Form – total | $120 |
| – Government payment (CPP) | $85 |
| – Patient payment (CPP2) | $35 |
| Drug Special Authorization Form (DSA) | $70 |
| Pre-Op Form (PreOp) | $120 |
| Medical EI Form (MEI) | $75 |
* Fees for other medically required forms will vary depending on the information required from the physician.