Uninsured Services Fee Schedule
Forms & Certificates
$150
DISABILITY TAX CREDIT
$150
$40
DISABLED PARKING FORM
$40
$30
DRUG PRIOR AUTHORIZATION FORM
$30
$30
DRUG SPECIAL AUTHORIZATION
$30
$25
FITNESS FOR WORK / SCHOOL / TRAVEL
$25
$60
MATERNITY LEAVE / EI FORM
$60
$50
MEDICAL EI / SHORT TERM DISABILITY CLAIM FORM
$50
$85
PROOF OF DEATH STATEMENT
$85
$25
SICK / RETURN TO WORK NOTE
$25
Examinations & Reports
$140
DRIVER'S MEDICAL
$140
$275
INDUSTRIAL HEALTH EXAMINATION
$275
$175
INSURANCE FORM ATTENDING PHYSICIAN'S STATEMENT
$175
$185
INSURANCE FORM WITH EXAMINATION
$185
$100
POWER OF ATTORNEY / TRUSTEE OF GUARDIANSHIP
$100
$160
PRE-EMPLOYMENT EXAMINATION
$160
$75
SCHOOL REQUESTED FORMS / MEDICAL EXAMINATIONS
$75
$240
THIRD PARTY LETTER
$240
Other Services
$75
TRANSFER OF RECORDS
$75
$35
TRAVEL ADVICE
$35
$5
TRAVEL VACCINE INJECTION (PER INJECTION)
$5