Uninsured Services

Missed Appointment Fees

$95.20

Diabetic driver report

$253

Employer’s occupational fitness assessment form

$217

Insurance company – long form

$241

Special authority form - for 3rd party insurer

$93.20

Transfer of records

$44.10

Driver’s medical examination report (blue stripe form)

$253

Income tax disability – long form

$241

Insurance company – short form

$184

Brief letter/note

$54

Liquid nitrogen treatment

$112.50

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

$253

Income tax disability – short form

$184

Insurance company – attending physician statement (APS)

$241

Brief certificate/form

$54