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