Charges for Uninsured Services (NOT COVERED BY OHIP) Ontario Medical Association (OMA) Guidelines TYPE OF SERVICE Completion of Form Physicals for: Schools/Camps DESCRIPTION OF UNINSURED FORM/REPORT/SERVICE FEE $26.00 Admission to Day-Care, Preschool, University or any other educ-al institution $26.00 Pre-employment Certification of Fitness/Fitness Clubs $34.00 Hospital/Nursing Home Employees $34.00 Drivers Medical Examination Completion of Licensing Forms/Certificates: Civil Aviation Medical Examination Report Pilots License Validation Administrative License Suspension Appellant Medical Info. Form Back to Work Notes/Sick Notes Completion of Work and School Federal Employee Absence Notes Related Forms/Notes: $52.00 Physician hrly rate Physician hrly rate $40.00 $18.00 $26.00 Day Care Note (free of communicable disease) $18.00 OCF-18 Treatment Plan $130.00 OCF-3 Disability Certificate $130.00 OCF-19 Determination of Catastrophic Impairment $107.00 Insurance Certificates: (Note: An OCF-22 Approval of an Assessment assessment fee can be charged in Travel Cancellation Insurance Form $122.00 addition to the insurance form fee if an assessment is necessary to obtain relevant information needed to complete the form) $44.00 Life Insurance Death Certificate Medical Certificate for Employment Insurance Compassionate Care Benefits $50.00 Attending Physician’s Statement $130.00 System – Specific or Disease Specific Questionnaire $87.00 Insurance Medical Examination $212.00 System-Specific Examination $104.00 Full Narative/Clarification Report Citizen and Immigration Canada Medical Report for Immigration Government Forms: Other Certificates: $349.00/hr $130.00 CPP Disability Medical Report Form $85.00 CPP The Narative Medical Report $150.00 Request for Medical Information re: Applicants to Canadian Armed Forces $102.00 Central Collection Service Request for Physician’s Information $130.00 Revenue Canada, Federal Disability Tax Credit $44.00 Auto Sales Rebate Form $35.00 Children’s Aid Society Application for Prospective Foster Parent $52.00 Medical Certificate Employment Insurance Sickness Benefits TB Test requested by Ministry of Health Program (eg. Public Health) TB Mantoux Testing*** $35.00 TB Test requested for admission or continuation in a day care, pre-school, school, college, university or other educational institution. TB Test Insured by OHIP. Charge for Form/Report Completion TB Test requested for employment purposes (Test + Form) $26.00 OHIP covered $20.00 $45.00 Application for Accessible Parking Permit/Transit Forms for Disabled Unremunerated Report Forms: (Physician is NOT permitted to PR Card Forms/Request for Birth Certificate Form/Canadian Passport Application charge a patient for completion) Children’s Aid Society Form (on behalf of a child)/Ministry of Health and Long-Term Care (eg. Limited Use, Assistive Devices etc.) Copies from the Patient’s Chart (up to 20 pages) Chart Copies: Copy of the Full Chart (over 20 pages). $30.00 + $.25 per page for each page over 20 pages. Letter for massage therapy, orthotics, back support, stockings etc. Missed Appointment Other: PAP Test*** No Charge $1.00/pg. $30.00 + $0.25/pg. $30.00 $40.00 Lost requisition/Referral $5.00 Fax Prescription refill $15.00 Travel Advice and Vaccine Administration (must be purchased from Pharmacy) $65.00 Charge for PAP Test by Physician $36.00 Processing Fee - payable directly to Processing Laboratory (e.g. CML) $20.00 *** MAYBE COVERED BY OHIP IF CERTAIN CRITERIA ARE MET
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