COST OF UNINSURED SERVICES

COST OF UNINSURED SERVICES

FORMS

DR’S CERTIFICATION SICK NOTE $20
MPI DRIVERS PHYSICAL/FORM $120
MPI ALCOHOL/DRUG REPORT FORM $20
DISABILITY INSURANCE CLAIM FORM $20/page
MODIFIED WORK DUTY FORM $20/page
PARKING PERMIT $40
CRA DISABILITY TAX CREDIT FORM $80
CRA DISABILITY TAX CREDIT FOLLOW-UP $40
PRE-OP PHYSICAL EXAM/FORMS (PRIVATE SURGERY) $120
SCHOOL/EMPLOYMENT/ADOPTIONS/SPORTS PHYSICAL/FORMS $120

FORMS

DR’S CERTIFICATION SICK NOTE
$20
MPI DRIVERS PHYSICAL/FORM
$120
MPI ALCOHOL/DRUG REPORT FORM
$20
DISABILITY INSURANCE CLAIM FORM
$20/page
MODIFIED WORK DUTY FORM
$20/page
PARKING PERMIT
$40
CRA DISABILITY TAX CREDIT FORM
$80
CRA DISABILITY TAX CREDIT FOLLOW-UP
$40
PRE-OP PHYSICAL EXAM/FORMS
(PRIVATE SURGERY)

$120
SCHOOL/EMPLOYMENT/ADOPTIONS/SPORTS
PHYSICAL/FORMS

$120

MANTOUX

MANTOUX (ALL VISITS, FORMS, RESULTS, INJECTIONS) $220

MANTOUX

MANTOUX
(ALL VISITS, FORMS, RESULTS, INJECTIONS)

$20

IMMUNIZATIONS

IMMUNIZATIONS (VISIT ONLY) NOT COVERED BY MB HEALTH $40

IMMUNIZATIONS

IMMUNIZATIONS (VISIT ONLY)
NOT COVERED BY MB HEALTH

$40

TRAVEL ADVICE

TRAVEL ADVICE CONSULT (VISIT ONLY) $40

TRAVEL ADVICE

TRAVEL ADVICE CONSULT (VISIT ONLY)
$40

PATIENTS WITHOUT VALID MHSC COVERAGE

CONSULTATIONS $120
FOLLOW-UP APPOINTMENT $60
SUTURES $300

*Any lab/diagnostic testing/forms not included

PATIENTS WITHOUT VALID MHSC COVERAGE

CONSULTATIONS
$120
FOLLOW-UP APPOINTMENT
$60
SUTURES
$300

*Any lab/diagnostic testing/forms not included

CLERICAL

PHOTOCOPIES $1/page
CHART TRANSFER FEE $40
+courier/mailing charges if applicable TBD

CLERICAL

PHOTOCOPIES
$1/page
CHART TRANSFER FEE
$40
+courier/mailing charges if applicable
TBD

MISSED APPOINTMENTS (24 HOURS OR LESS)

MISSED REGULAR APPOINTMENT $40
MISSED COMPLETE PHYSICAL APPOINTMENT $80

*24 Hour cancellation notice required
**Please note- The 3rd missed appointment may result in termination from practice

MISSED APPOINTMENTS (24 HOURS OR LESS)

MISSED REGULAR APPOINTMENT
$40
MISSED COMPLETE PHYSICAL APPOINTMENT
$80

*24 Hour cancellation notice required
**Please note- The 3rd missed appointment may result in termination from practice