Uninsured Services

Missed Appointment Fees

$97.20

Diabetic driver report

$258

Employer’s occupational fitness assessment form

$222

Insurance company – long form

$246.10

Special authority form - for 3rd party insurer

$95.20

Transfer of records

$45.50

Driver’s medical examination report (blue stripe form)

$258

Income tax disability – long form

$246

Insurance company – short form

$188

Brief letter/note

$55.10

Liquid nitrogen treatment

$114.90

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

$258

Income tax disability – short form

$187.90

Insurance company – attending physician statement (APS)

$246.10

Brief certificate/form

$55.10