Uninsured Services
Based on our commitment to providing you with the timely and adequate medical care, there are however, services that you may request from your doctor that are not considered medically necessary by Ontario Health Insurance Plan (OHIP) and are therefore not paid by OHIP. These services, such as: insurance forms, legal letters, sick notes, cosmetic medical procedures, etc., are called “non-insured or uninsured services”. Ivory Medical Clinic will charge for uninsured services in accordance with the fees guidelines set by the Ontario Medical Association (OMA) and the College of Physicians and Surgeons of Ontario (CPSO).
The following list accounts for most commonly requested uninsured services. However, if the service you request is not on the list below, please communicate it to the clinic’s staff or your doctor and you will be given further clarification.
All uninsured services must be paid in full when rendered. A receipt will be provided upon settlement of the account. Please be advised that, currently, our office only accepts cash for these services.
MEDICAL EXAMS
Basic Visit (no or invalid OHIP) evenings or holidays. $85
Basic Visit (no or invalid OHIP) weekdays $65
Child Annual/Camp Physical $35
Driver’s medical examination (form not included) $140
Major Visit/Adult Physical $70
Physical Examination Required by Third Party $120
Travel Advice $60
FORMS/NOTES
Attending Physician’s Statement $125
Back-to-Work Note $25
Certificate of Medical Status $25
Children’s Aid Society Application for Prospective Foster Parent $55
Clarification Report OMA Guidelines
CPP Disability Medical Report Form $110
Day Care Note (Free of Communicable Disease) $25
Driver’s Medical Exam (MOT, FLRC80 Form + Physical) $145
Driver’s Medical Exam (MOT, FLRC80 Form Completion only) $45
EI Disability/Maternity Report $25
Employment Insurance – Maternity Certificate $25
Fitness Club Form $45
Full Narrative Report OMA Guidelines
General Questionnaire $30
Jury Duty Letter $25
Lawyer’s Letters OMA Guidelines
Letter on Behalf of Patient $50 – $300
Life Insurance Death Certificate $55
Lost Prescriptions / Referral Notes $20
Massage Therapy, Orthotics, Physio, Compressing Stockings, etc. $20
Medical Certificate for EI Compassionate Care Benefits $45
Medical Report-Canadian Immigrants $100
Ontario Accessible Parking Permit (For People with Disability) $25
Other Insurance Forms OMA Guidelines
Pre-Employment Certificate of Fitness $40
Prescription by Fax / Phone $20
Private Insurance Sickness and Disability – Long Term $90
Private Insurance Sickness and Disability – Short Term $60
Revenue Canada/Federal Disability Tax Credit $50
School, Camp Physical (Form only) $25
Sick Note $25
System or Disease Specific Questionnaire $70
Travel Cancellation Form $45
Treatment Plan Form $100
PROCEDURES
Excision & Suture of Moles, Cysts, Lipomas (first lesion) $80
- Each additional $30
Seborrheic Keratosis $40
Skin Tags Removal and other cosmetic procedures $50
Wart-cryotherapy (first wart) $25
- Each additional wart $10
IMMUNIZATIONS
(HEP A, HEP B, Twinrix, HPV/Gardisil, Menactra,Zostavax/Shingles,Thyphrix,Avaxim)
Injections needed for Travel $15
TB Mantoux One Step Test $50
TB Mantoux Two Step Test $70
OFFICE/ADMINISTRATIVE
Missed Appointment without 24hr notice $50
Missed Physical Examination $80
Transfer of Medical Records
First 1-5 pages $30
- Each Page After 5 $1
Prescription Renewal by Fax (when Appropriate) $20
