2016-2017 Schedule of Fees for Uninsured Service

Simple Forms & Fee

• Missed / Return to Work / School – $20.00
• School / Camp – $25.00
• Admission to Daycare / Preschool / College / University – $35.00
• Pre-Employment Certification for Fitness/Fitness Clubs – $35.00
• Hospital / Nursing Home Employees – $35.00
• Federal Employee Absence Notes – $25.00
• Certificate of Freedom from Communicable Disease – $20.00
• Certificate of Disability (Insurance Company Form) – $40.00
• Registered Massage Therapy Note (requested for insurance) – $20.00
• Chiropractic Care Note (requested for insurance) – $20.00
• Custom Made Orthotics / Orthopedic Footwear Note – $20.00
• Simple forms not otherwise listed (per page) – $20.00

Licencing Forms & Fee

• MTO Driver’s Licence Application / Renewal – $95.00
• Application for Driver’s Assessment (reinstating of licence) – $50.00

Insurance Certificates & Fee

• #OCF-18 Treatment Plan – $129.50
• #OCF-3 Disability Certificate – $129.50
• #OCF-8 Certificate of Health Practitioner – $106.25
• #OCF-19 Determination of Catastrophic Impairment – $35.00
• Travel Cancellation Insurance Form – $45.00
• Life Insurance – Death Certificate – $45.00
• Medical Certificate for Employment Insurance Compassionate Care Benefits – $50.00
• Government Forms & Fee
• Citizen and Immigration Canada medical report – $125.00
• CPP Disability Medical Report Form – $129.50
• Request for Medical Information for Canadian Armed Forces applicants – $100.00
• Central Collection Service Request for Physician’s Information – $125.00
• Revenue Canada Federal Disability Tax Credit – $45.00
• Auto Sales Tax Rebate Form – $35.00

Life/Health Insurance Assessments and Reports & Fee

• Attending Physician’s Statement (without medical exam) – $139.85
• System – Specific or Diseases Specific Questionnaire without medical exam – $85.00

Office Procedures & Fee

For travel vaccine administration, please talk to Doctor or Nurse, and then book an appointment with reception. This is a separate office visit, there is a fee associated with this visit as this service is not covered by OHIP.

• Skin Tag Removal (per 10) – $100.00

Non-cancerous moles:

• Face – $100.00
• Body (Initial mole) – $75.00
• Body (Each additional lesion) – $50.00
• Wart treatment with cryotherapy (per lesion, except for feet or genitals) – $10.00