Fee Guide
Welcome to the Chapel Hill Health Center
Now partnering with Healtheon to provide even better service for you and your family.
| Forms | Non-Member Fee | Plan Member Fee | |
|---|---|---|---|
| Drivers Medical Exam/Pension Buy back and Form | $250 – $300 | $187.50 – $225 | |
| Drivers Medical Form only | $70 | $52.50 | |
| Aviation Medical Exams/forms | $300 | $0 | |
| Ottawa Hospital/OC Transpo Medical Certificates | $50 | $0 | |
| Camp, School, University forms | $35 | $0 | |
| Routine Sick Notes/Back to work Notes | $25 | $0 | |
| Jury Duty Letter | $40 | $0 | |
| Drug Exemption Insurance forms | $50 | $0 | |
| Paramedical Prescriptions (i.e., massage, physio etc. without appt) | $25 | $0 | |
| Travel Cancellation Form | $100 | $75 | |
| Functional Abilities forms | $50 | $0 | |
| Pre-Adoption/Foster form only | $100 | $75 | |
| Pre-Adoption/Foster exam + form (CAS) | $250 | $187.50 | |
| Free communicable disease certificate | $25 | $0 | |
| Vaccine review and forms (work/school) | $40 | $0 | |
| Pre-Employment (i.e., Fitness/hospital/nursing) certificate | $45 | $0 | |
| Modified Duty/Return to work treatment form | $40-$100 (As per complexity) | $0 |
| Insurance Reports | Non-Member Fee | Plan Member Fee | |
|---|---|---|---|
| Insurance forms | $50-$300 (minimum $50, as per complexity) | $0-$225 | |
| Attending Physician Statements | $160 minimum – $160-$300 (as per complexity) | $120-$225 | |
| OCF-3 Disability Certificate | $240 | $180 | |
| OCF-18 Treatment Plan | $255 | $191.25 | |
| OCF-19 Determination of Catastrophic Impairment | $140 | $105 | |
| OCF-23 Treatment Confirmation | $240 | $180 | |
| Life insurance Death Certificate | $50 | $0 |
| Government Forms | Non-Member Fee | Plan Member Fee | |
|---|---|---|---|
| CPP Disability Medical Report Form (Government covers $85.00) | Patient pays $65, $150 balance | $0 | |
| CRA Disability Tax Credit (T2201) | $100 (additional fees as per complexity) | $75 | |
| Federal Government Absence Certificate | $50 | $0 |
| UNINSURED EXAMS/PROCEDURES | Non-Member Fee | Plan Member Fee | |
|---|---|---|---|
| Private Patient Periodic visits | $235 | $176.25 | |
| Private Patient Routine visits including children check-ups | $100 | $75 | |
| Private Patient injections only without visit | $20 | $0 | |
| Chart Transfer | Child | $50 | $0 | |
| Chart Transfer | Adult | $75 | $56.25 | |
| Work related to TB Test and Form | $75 | $56.25 | |
| Warts (cryotherapy) | $40 | $0 | |
| Ear syringe | $40 | $0 |
The Following Services are NOT Covered by the Wellness Plans
| Service | Non-Member Fee | Plan Member Fee | |
|---|---|---|---|
| Missed appointment without 24 hour notice | $50 | $50 | |
| Chart photocopying requested by patient/insurer | $30 – 1st 20 pages + $0.25/page subsequently | $30 – 1st 20 pages + $0.25/page subsequently |