Insurance Forms and Non Insured Services

Most insurance and other types of forms are services not covered or paid for by Alberta Health. The most common forms that your surgeon will fill are related to short or long term disability following surgery or another procedure, or an attending physician’s statement. These forms reflect the expertise, long training, and professional opinion of your physician.

Payment is required prior to forms being released, and these forms will form part of your medical record.

The following services ARE NOT COVERED by Alberta Health.

You are required to pay for these services prior to receiving them.

SERVICES                                                                                                            FEES

No show or Cancellation of office visit with less than 24 hours notice $100.00

No show or Cancellation of procedure or surgery with less than 3 business days notice $150.00

Out of Province Patient without verification of provincial coverage $100.00

Out of Country Patient Appointment $200.00

COMPLETION OF FORMS

Blue Cross Special Authorization Forms $55.00

Attending Physician’s Statement (for insurance company)                     

                    Single Page (simple) $100.00

                     Multiple Pages (complex) $150.00

Fitness for Work Form $75.00/pg

Doctor’s Letter $50.00  

Chart Copy of Medical Records for Patient or Care Transfer $35.00 + $0.25/pg

Lawyer Chart Request (varies by situation)                                              $300.00 - $600.00

Hernia Belt                                                                                                                      $79.99 + tax