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.

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:

1. Pay for each uninsured service at the time of request and prior to its delivery; or

2. Pay an annual block fee of $150 per individual or $250 per 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, You may come in person to the office to pay, contact us over the phone with your credit card information or send and etransfer to, theoffice@midtownmedical.ca, please ensure your name/s and date of birth are on the notes section of the e-transfer to ensure the block fee is linked with the correct person/s.

** 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 requests prescription renewals outside an appointment, the applicable fee will be charged to you, unless you have paid the annual block fee.

Additional information is available on our website

With best regards,

Dr. R Martins, Dr. J Masgoret, and Dr. M Fomina-Nazarova

Midtown Medical

Uninsured Services
Uninsured Services Fee Yearly Plan
Prescription Renewal/Reissue (over the phone/fax)(3 per year) $20.00 Covered
Sick note/Back to work note $25.00 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 $50.00 Covered
Driver’s Medical + Examination Form    $190.00
Driver’s Exam Form    $80.00    Covered
CPP Disability - Time Based $100-$300
Disability Tax Credit $150.00
EI Disability $50.00 Covered
Compassionate Care $70.00 Covered
Travel Cancellation Form/Travel accessibility letter $160.00 Covered
*Referral Note for Chiropody, Physiotherapy, Chiropractor, Massage $25.00 Covered
And Orthotic Prescription
**Other Forms not Covered by OHIP $30.00- Covered
Uninsured Travel Vaccinations/Counselling $50.00+ 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 - Administration fee $30.00    Covered
Ear wax clearing $20.00 Covered
Mailing documents to patient at patients request/Printing blank doc. $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 $40.00 Covered
Insurance Drug Authorization Form $50.00 Covered
Forms and certificates are uninsured when they are requested by the patient and transmitted to a third party.
Forms exceeding $30.00, are excluded from plan.
This list is not comprehensive, please consult with admin staff regarding fees.

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.

Yearly Family Plan (Max 4 Living under the same roof) $250.00
Yearly Single Plan ***************************************************** $150.00

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. 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) _