Uninsured Services

Insurance Forms

General insurance eligibility (exam and form) - $175

Attending physician’s statement (form only) - $150

Massage note for insurance coverage - $25

Administrative Services

Transfer of medical chart to another physician office - $20 (minimum charge)

Variable Fees for copy of medical records to a third party

Variable Fees for medico-legal reports/copies of medical records

Disability Benefit Report:

Form - $150

Form and exam - $200

Third party requested letter on patient attended - $300

Medical Fitness Forms

Certificate of fitness form - $75

Certificate of fitness form and exam - $150

Driver's medical examination and form completion - $150

School and Employment Forms

Certification of fitness for school/work form - $75

Certification of fitness for school/work form and exam - $150

Academic accommodation forms - $25

School requested forms and report - $150

Sick note - $25

Clinical Services

Uninsured office visit, regular appointment - $100

Uninsured office visit, mental health visit - $275

Wart treatment, per treatment - $10