Dr. Lance Lev y M.B., Ch.B., M.Sc, FRCP(C) L.L. Med. Prof. Corp. The Clinic for Bariatric Medicine & Refractory ObesitY Comprehensive, multidisciplinary evaluation & treatment for teens & adults with obesity & co-morbid conditions (ADHD, mood disorders, sleep disorders & chronic pain). 2015 Un-insured Services Fee Agreement Form Patients’ name: ____________________________________. Today’s Date:____________ Read and Select one of the following 3 options. Please circle the number to indicate your choice. 1. Block Fee Billing divided into a series of charges per visit. each visit fee charge $35. (The total charge will not exceed $ 590 per annum.) 2. Fee for Service charges will be made based upon the time taken by Dr. Levy to deal with your needs regarding Un-insured services. Fee for service charges are based upon 6 minute increments of time spent (or part thereof) with each 6 minute unit being billed at $40. The hourly rate is $400. 3. No Un-insured services please. (this needs total rewriting) I will pull a template for this from previous clients to use as an outline I have read and understood the foregoing description of fees and services, and choose the following option. I understand, and agree, that this agreement will remain in force until I revoke it. print Name: ________________________________ Signature of patient: ________________________________ By Referral Only: 174 Duplex Ave. • Toronto, Ontario M5P 2A9 (Phone) 416-489-0180 • (Fax) 416-488-3844 By Referral Only: 174 Duplex Ave. • Toronto, Ontario M5P 2A9 (Phone) 416-489-0180 • (Fax) 416-488-3844