600 Sherbourne St, Unit 212 Toronto, ON, M4X 1W4

Oct 31, 2022

Dear Patient,

I want to thank you all for your support and patience over the last several months. While the stress of living with and adjusting to life during the pandemic was challenging, I considered myself fortunate to be able to work every day and continue to provide care the best I could.

We are very fortunate in this country to have access to good health care paid for by the Ministry of Health through our taxes. As our population ages the cost of health care continues to rise and as a result there are more and more services that are not covered by the ministry. They require significant time and resources to administer. The demand for these uninsured services has increased dramatically in the past few years. In the face of rising office expenses and government restrictions, we are unable to provide these services free of charge. Therefore the payment of these services has become the responsibility of the patient.

I would like to touch on the issue of renewals of prescriptions by phone or fax. Each time a request is made by fax or telephone for a prescription renewal without an office visit:: the patients chart needs to be accessed, it then needs to be reviewed by the physician, the necessary documentation’s need to be added to your medical file, and then the prescription needs to be sent to the pharmacy. Please make sure you allow several days’ notice when requesting prescription renewals If you sign up for the Annual Block fee for uninsured services prescription renewals will be covered, otherwise there will be a charge for each request made by phone or fax. During any office visit, you should request a renewal of your prescription(s). It is important to bring all medications to every visit. Doing this will reduce time spent on this administrative task

Signing up for the all-inclusive Annual Block fee can also amount to substantial savings if other uninsured services arise over the year. Included with this letter is a list of uninsured services which are covered by paying the Annual Block fee.

Those who choose not to sign-up for the optional Annual Block fee may pay for individual uninsured services at the time the services are provided.

Should you wish to submit payment for the Annual Block fee using a debit or credit card, you may do so online by going to www.doctorsservices.ca/online-payment or by telephone to Doctors Services. I am continuing to use DOCTORS SERVICES to administer this plan. Any questions, issues or correspondence regarding the plan should be directed to them by phone 1-866-423-8267 and NOT to our office.

I look forward to continuing to provide your primary medical care to ensure that you receive the best possible health outcomes..

Yours Sincerely,

Dr. Lorena Barrientos

The Following Un-Insured Services ARE COVERED by paying the Annual Fee General Un-Insured Services

Prescription Renewals by phone/fax (when appropriate and only at the request of the patient or their pharmacy)* $ 25.00 -per request
Ear Wash $ 40.00
APS (Attending Physician Statement) $ 150.00
Illness and Return to Work Notes $ 30.00
Massage Therapy and Orthotics $ 35.00
Day Care Notes $ 30.00
School / Camp Forms $ 30.00
Travel Cancellation Forms $ 50.00 -$75 Depending on Length
Referral Note for Chiropractor, Physiotherapy, etc. $ 35.00
Transfer of Medical Records First 20 pages $ 30.00 Each page after 20 $ 0.25
Letters on behalf of patients $ 35 – 200 Depending on time and work involved
Medical Supplies, Dressings, etc. $ 25.00
Lost Prescriptions, Notes, Referrals $ 20.00
Uninsured Vaccine Administration $ 25.00
TB Test & Reading $ 40.00 – per test TB Form only: $20.00
Medical Examination for Return to Work requested by Employer $ 75.00
Driver’s Medical Form (MOT) $ 160.00
Third Party Physical Exam $ 160.00
Photocopying/Printing $ 1.00 per page
Travel info/vaccination $ 40.00
Medical Report / Forms
OCF-3 Disability Certificate $ 160.00
Commercial weight loss program $ 30.00
Employment Insurance / Maternity Certificate $ 30.00
Fitness Club Forms $ 42.00
Private Insurance Forms $ 30 – $ 500 Depending on time and work involved
Pre-employment Certificate of Fitness $ 42.00
Jury Duty Letter $ 35.00
Certificate of Medical Status $ 30.00
Revenue Canada Disability Form $ 83.00
Disability Tax Credit Certificate $ 85.00
Children’s Aid Society Forms $ 50.00 application for prospective foster parents
Replacement of Immunization Certificate $ 40.00
Forms required for Volunteer Work $ 30.00

*Prescription renewals require an office visit to reassess the medical condition requiring the prescription. Please anticipate your renewals at your office visit.

The Following Uninsured Services ARE NOT COVERED by the Annual Fee

Available as per the standard guidelines set by the Ontario Medical Association-OMA.

Missed Appointment $ 40.00
Missed Annual Physical Examination $ 100.00
Insurance/Disability Forms OMA Rate
Legal Reports OMA Rate


We are using ‘DOCTORS SERVICES’ for the administration of this plan. Doctors Services handles all preparation, mailing, and receipts for the Annual Fee. If you have any questions regarding your payment, please contact Doctors Services at 1-866-423-8267. Please do not contact our office.

Please fill out the form below, fold and insert the completed form into the return envelope provided.

Postage has been prepaid.

For further information regarding Annual Fees please go to:


Patient Name Primary Health Care Provider Patient Name Primary Health Care Provider

[ ] Option A – I enclose annual fee Credit Card [ ] Cheque  [ ]

Coverage is from: December 1, 2022 – November 30, 2023

*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).


Please accept my payment for the Annual Coverage Program.

[ ] Individual $ 135.00
[ ] Couple $ 205.00
[ ] Family* $ 240.00
[ ] Senior (65+) $ 110.00
[ ] Senior Couple $ 150.00

I am requesting coverage as a:

* (including children under 21 and residing at the same address)

Cheques should be made payable to: DR. LORENA BARRIENTOS

Credit Card Details

Name on the Card

Card # Expiry Date




(3-digit code on back of card)

[ ]  Option B – I wish to pay for individual services when rendered

*If you choose option B and do not wish to include your email address there is no need to return the form.