Extended Coverage for April 1, 2015 to March 30, 2016.

The Tillsonburg Medical Centre is once again offering the option of the Annual Fee Program for Extended Coverage, as this choice is preferred by many patients. As you are aware, the Ontario Health Insurance Plan pays for most medical services. However, some medical procedures and most administrative services are not insured under Ontario’s provincial health care system. Therefore, payment for these is responsibility of either the patient or the agency requesting the service.

Attached is a list of individual pay per service fees.The option to enroll in the Annual Fee program can amount to substantial savings for patients as unexpected needs arise over the year. If you would like to enroll in this program, complete the enclosed form and return it to our office. Please update any family and demographic information.

Uninsured Services Fee Guide
The Ontario Health Insurance Plan (OHIP) Does not pay for the following Uninsured and Third Party Requested Services

Included in Annual Fee

(Uninsured Services) Fee
Prescription Renewals by telephone/fax at the request of patient or pharmacy $15.00
Adoption Forms $50.00
Auto Sales Tax Rebate Form $20.00
Canada Pension Plan Disability Report $30.00
E.I.C. Disability/Maternity Certificate or Letter $25.00
Fitness Club Physical Form $20.00
Immunization Record Summary $20.00
Pre-Employment Fitness Certification $35.00
Return tor Work/Maternity Form $25.00
Revenue Canada Disability Tax Credit Form $45.00
Sports/Camps/School/Day Care Form $25.00
Travel Cancellation Insurance Form $35.00
Travel Medicine Prescription $25.00
Massage/Orthotics Prescription $20.00
Life Insurance Death Certificate $40.00
Record Transfer/Chart Summary to Other Physician $30.00 – $100.00

Not Included in Annual Fee

Uninsured Services Fee
Driver’s Physical & Form $100.00
Missed appointments without notice $35.00
Pre-op for non-OHIP Surgery (eg. Cosmetic) $100.00
Lost Requisitions blood work/testing requisitions $15.00
Personal/Insurance Medicals Minimum $100.00
Legal Letter Hourly Rate $300
Secretarial Services per 15 minutes $5.00
Photocopies per page $1.00
Facsimile per page $3.00
Liquid Nitrogen for Single Non-Planter Wart, per visit $15.00
Liquid Nitrogen for Multiple Non-Planter Wart, per visit $30.00
Liquid Nitrogen for skin tags, molluscum, actinic/seborrheic keratoses, per visit $25 per visit
Third Party Requested Services to be paid by third party $25.00 – $200.00