As you are aware, these are difficult times for patients ... - Mydoctor.ca

200 St. Clair Ave W. Suite 110
Toronto, ON, M4V 1R1
(Tel) 416-928-9343
Dear Patient, Aug 4, 2010
As you are aware, these are difficult times for patients and doctors. Limited resources, additional paperwork,
and accelerating costs have forced doctors to charge for services OHIP does not pay. Examples of such
services include: telephone renewal of prescriptions, telephone contact between patients and physician, and the
completion of medical certificates for employers, school, and government applications. A more complete list
follows.
Since the opening, our office has offered an alternate to billing patients directly for those services.
Instead of charging patients each time one of these services was performed, patients could choose the option
of paying a single annual fee.
Once again that option is available. However, the program will be administered by a different firm. It will be
administered by Doctors Services Group.
Unlike last year, all patients will be covered for the same period of time - from October 1st, 2009 to
September 30th, 2010. No longer will individual patients be covered for different periods of time. This will
mean that the program will run more smoothly.
For those who have already submitted the annual fee, an adjustment will be made so that payment will be
required for only the unpaid portion of the October 1st, 2009 to September 30th, 2010 period.
Please complete the enclosed form and return it in the accompanying postage-paid envelope.
If you have any questions about the program, please contact Doctors Services Group at 416-447-3666; if you
have any additional concerns, please contact our office.
Attached is a list of the individual services covered by the single annual fee. Only those who decide not to pay
the annual fee will be charged these services.
Sincerely,
Dr. Jason Baker, Dr. S. Ellen Morch, Dr. Mark Appelby, Dr. Sharon Hind

The Following Uninsured Services ARE Covered by the Annual Fee
Prescription refills by phone/fax (when appropriate and
only at the request of the patient or patients
representative) *
$20.00 Letters on behalf of patients (when appropriate and
depending on work required)
$40 - $200
Telephone advice (during office hours - 5 mins)** $20.00 Missed Annual Physical/ Counselling Session*** $120.00
Missed Appointment*** $60.00 Photocopying/Faxing**** $20.00
Third party physical exam $120.00 Wart Treatment (per lesion)******** $20.00
Travel Consult in the office $60.00 Driver’s Medical Examination and Form $140.00
TB Skin Test (per step)******* $40.00
Medical reports/forms ( without examination)
Forms required for volunteers at nursing homes/hospitals $25.00 Special forms for insurance coverage of Massage
therapy, Orthotics, Physiotherapy, Chiropody,
Chiropractic and Acupuncture*****
Forms required for commercial weight loss programs $25.00 Day Care Notes ( communicable disease ) $20.00
Illness/return to work notes ( simple and only where
appropriate) )
$20.00
$20.00 School/Camp Form (excluding examination) $25.00
Employment Insurance / Maternity Certificate $40.00 Camp/School physical form $40.00
Fitness Clubs Form $40.00 Travel cancellation insurance form $40.00
Private Insurance forms (form fees reimbursed by a third
party are not covered by the block fee)
$50 - $200 Auto Sales Tax Rebate Form $40.00
Pre-employment Certificate of Fitness forms $40.00 Transfer of Medical Records****** $50.00
Jury Duty Letter $20.00 Canada Pension Plan disability benefits
application forms (The federal government pays
$65 of the $125 fee)
Disability Tax Credit Certificate (Form T2201 - Canada
Revenue Agency)
(Filling of the form does not ensure qualification for the
program)
$40.00
The Following Uninsured Services are NOT Covered by the Annual Fee
They are available to all patients at standard OMA rates
Disability Report/Insurance Forms OMA Rate Legal Reports OMA Rate
Excision of Benign Lesion $50.00 + Participating is a case conference on your behalf
(per half hour)
$60.00
OMA Rate
Vaccines that are not normally covered by OHIP Varies Physical Exam requested by a third-party OMA Rate
* Five (5) per year. Prescription renewals ordinarily require an office visit to re-assess the condition requiring the prescription. If
you do not wish to schedule an appointment to review your medication, we will charge for this service. Please anticipate your
renewals, ask for renewals at each visit and bring your medications for your appointments.
** At doctor's discretion. Four (4) per year.
*** Total of one (1) missed appointment per year. Applies unless 24 hours notice given.
**** For personal use or at the request of a third party. Maximum 10 pages.
***** Per certificate
****** When requested by patient, for transfer of care to another physician.
******* Each "step" includes injection, and interpretation with reporting at 48 hours.
******** Wart treatment is uninsured when lesions are not on the foot.

Please fill out the form below, fold and insert the completed form into the return envelope provided. Postage
has been prepaid.
If you choose the family fee please circle the family members listed, or print their names on the lines provided.
Additional patients covered by the Annual Fee Program
______________________________ ______________________________ ____________________________
Surname, FirstName Surname, FirstName Surname, FirstName
______________________________
______________________________
____________________________
Surname, FirstName Surname, FirstName Surname, First Name
Please circle your doctor from the list below if not the same as printed in the details above
Dr. Baker Dr. Appelby Dr. Morch Dr. Hind
Option A – I enclose annual fee Visa/MasterCard Cheque
*Please note that it is your right to rescind the decision to pay annual fees within a week of your original decision (in
which case you will be required to pay for services as provided).
Coverage is from October 1st, 2009 – September 30th, 2010
Please accept my payment for the Annual Coverage Program.
I am requesting coverage as a: Individual $ 130.00
Cheques should be made payable to: Your Primary Care Provider
Name on Credit Card_____________________________________
Family $ 195.00
(Please note that children over 18 in school full time or in care of
parents/guardians will be covered under the family plan )
Card #______________________________________________
Expiry Date _______
Signature ____________________________________________
Receipt – Please check here if you require a receipt