UNINSURED SERVICES INFORMATION

Dear Patient,

As your family doctors, we endeavor to provide the highest level of primary care to you and your family. Our focus is on delivering medically necessary services covered by OHIP. However, not all services requested of physicians are covered by OHIP. And, increasingly, we are being asked to provide more of these non-OHIP services. This has resulted in a marked increase in our workload and in the cost of running our office.

While we have not been billing for these non-OHIP insured services for the past two years, we are obliged to resume billing for them now to help us manage the requests for non-OHIP insured services. Effective September 1st, 2022 we will resume billing you directly for uninsured services. The fees we will be charging are set out on the attached schedule and are in accordance with the Ontario Medical Association (OMA) guidelines.

Accordingly, you will have the option to either:

Pay for each uninsured service at the time of request and prior to its delivery; or
Pay an annual block fee of $125 per individual/$200 family (up to 4 people living in the same household) which will cover most of these uninsured services.

The annual block fee will provide you with coverage for the most common uninsured services such as prescription renewals outside of an appointment; doctor's notes; missed appointments and several other items set out on the attached list. The block fee is designed to be a reasonable amount relative to individual service costs; to save you the inconvenience of dealing with individual bills and delays for each individual service; and to help manage the administrative costs of collecting for uninsured services.

If you wish to pay the block fee, please fill the attached form and return it to the office either by fax/email/mail or in person. Alternatively, you may also email and e-transfer to, theoffice@midtownmedical.ca, please ensure your name and date of birth are on the notes or you may call the office with your credit card information.

** Special Note on Prescription Renewals. Prescription renewals outside of a doctor’s appointment are very commonly requested both by patients and their pharmacies. Please note that your doctor has provided you enough medication to last you until your next recommended appointment. We encourage you to bring your medications to each appointment so your doctor can review them and renew them as needed at the appointment. Should you run out, your pharmacy has the option to bridge most of your medications until you are able to see your doctor again. The pharmacy is not required to get authorization from your doctor.

If you or your pharmacist request prescription renewals outside an appointment, the applicable fee will be charged to you, unless you have paid the annual block fee.

With best regards,

Dr. R Martins, Dr. J Masgoret, Dr. M Fomina-Nazarova, Dr. S Chung Midtown Medical

Uninsured Services
You may either purchase the plan below for 1 year or pay for individual services. If you choose to pay for each individual service, you will be asked to pay for each service according to the guidelines recommended by the Ontario Medical Association.
Uninsured Services Fee Yearly Plan
Prescription Renewal/Reissue (over the phone/fax)(3 per year) $20.00 Covered
Sick note/Back to work note $20.00 Covered
Missed Routine Appointment/Physical $50.00
TB Skin Test/Form $40.00 Covered
Transfer of Medical Records $35.00 + Covered
Pre-employment Certification of Fitness/ School/Camp Forms $40.00 Covered
Driver’s Medical + Examination Form    $150.00
Driver’s Exam Form    $75.00    Covered
Citizenship and Immigration Report $50.00    Covered
CPP Disability/Disability Tax Credit    $85.00
EI Disability/Maternity Cert. INS2019/Compassionate Care    $40.00 Covered
Travel Cancellation Form/Travel accessibility letter $40.00    Covered
*Referral Note for Chiropody, Physiotherapy, Chiropractor, Massage $20.00 Covered
And Orthotic Prescription
**Other Forms not Covered by OHIP $30.00 - Covered
Uninsured Travel Vaccinations/Counselling $30.00 Covered
Lost bloodwork/other testing replaced/replace lost vaccine card $20.00 Covered
Rebooking of missed specialist or test appointments $20.00 Covered
Wheel Trans Application $30.00    Covered
Ear wax clearing/urine pregnancy tests $20.00 Covered
Mailing documents to patient at patients request $5.00 Covered
Minor Medical Procedures $50.00 +
Medical/Legal Report $150.00+
Liquid Nitrogen for benign skin lesions/warts $35.00+
Pap Test done earlier than funded by OHIP $100.00
Hearing Aid application for funding $20.00 Covered
Insurance Drug Authorization Form $40.00 Covered
Forms and certificates are uninsured when they are requested by the patient and transmitted to a third party.
This list is not comprehensive, please consult with admin staff regarding fees.

Yearly Family Plan (Max 4 Living under the same roof) $200.00
Yearly Single Plan ***************************************************** $125.00

1 - Plan can be purchased by calling the office with a credit card.
2 - e-Transfer to: theoffice@midtownmedical.ca, please ensure name/s, and date of birth/s, of patient/s are sent in e-transfer note, or a separate email to ensure plan is added to correct patient/s.
3 - Cheque addressed under your physician’s name:
Dr. Rui Martins Medicine Professional Corporation
Dr. John Masgoret Medicine Professional Corporation
Dr. Shari Chung Medicine Professional Corporation
Dr. Marina Fomina-Nazarova
Full Name/s ________________
Address
Phone Number
Name on Credit Card _
Credit Card Number
Expiry Date _____
CVV (three numbers at the back of card) _