Uninsured Services

Missed Appointment Fees

$93.30

Diabetic driver report

$248

Employer’s occupational fitness assessment form

$205

Insurance company – long form

$236

Special authority form - for 3rd party insurer

$91.40

Transfer of records

$43.25

Driver’s medical examination report (blue stripe form)

$248

Income tax disability – long form

$236

Insurance company – short form

$180

Brief letter/note

52.90

Liquid nitrogen treatment

$110

Driver’s license examination – full exam (yellow stripe form)

$248

Income tax disability – short form

$180

Insurance company – attending physician statement (APS)

$180

Brief certificate/form

52.90