Fee Guide for Uninsured Services

Uninsured services COVERED by the Basic Wellness Plan

Form fee policy/disclaimer:
If a membership is cancelled or expires, and the cost of a medical form completed by your healthcare provider during the membership period exceeds the membership fees paid, the member is responsible for paying the difference for the forms.

General Uninsured Services

Service Price
Prescription Renewals by phone/fax/online (when appropriate and only at the request of the patient) $25.00
Letters on behalf of patients (depending on time and work involved) $25 – $200
Wart Treatment $30.00/treatment
Lost Prescriptions, Notes, Referrals $25.00
TB Skin Test(3rd Party Request) $50.00
TB Test + Reading $40.00
Medical Examination for Return to Work requested by Employer $75.00
Third Party Physical Exam $160.00
Photocopying – Transfer of Medical Records $30.00 first 20pg, $0.25/pg after
Ear Cleaning $40.00

Medical Report/Forms

Service Price
Citizenship and Immigration Report $50.00 – $75.00
Commercial weight loss program $45.00
Illness and Return to Work Notes $25.00
Employment Insurance / Maternity Certificate $45.00
Fitness Club Forms $25.00
Private Insurance Forms $30 – $200
Pre-employment Certificate of Fitness $45.00
Jury Duty Letter $25.00
Certificate of Medical Status $25 – $35
Massage Therapy and Orthotics $25.00
Revenue Canada Disability Form $150.00
Day Care Notes $25.00
School / Camp Forms(Excluding Examinations) $35.00
School / Camp Physical Examinations $75.00
Travel Cancellation Forms $50.00
Referral Note for Chiropractor, Physiotherapy, etc. $25.00
Children’s Aid Society Forms $45.00
Replacement of Immunization Certificate $15.00
Forms required for Volunteer Work $45.00

The following uninsured services are NOT COVERED by the Basic Plan

Available as per standard Provincial guidelines

Service Price
No show/late cancellation $40.00
Missed Annual Physical Examination $80.00
Attending Physician Statement $160.00
Driver’s Medical Form (MOT) (non-subscriber, $150.00) Basic plan subscriber $75.00
Legal reports SMA rate
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