K053

PDF page 820 / AF2

APPENDIX F
Appendix F does not form part of the Schedule of Benefits: Physician Services under the
Health Insurance Act and is reproduced for your information only.
      2.For physicians other than ophthalmologists, claims submitted for any other service by the
        same physician the same day as either of these services are not eligible for payment.
      3.This payment represents full payment for the service. No additional charge to either OHIP or
        the patient for this service is permitted.
MCCSS ONTARIO WORKS PROGRAM (OW)
 K053 A Limitation to Participation Form ...........................................             17.45
     Note:
     The MCCSS forms identified above are provided to patients only by social services staff. The
     fee codes are specific to the applicable form and are not to be claimed for completion of any
     other government document. Inquiries regarding MCCSS forms may be directed to the local
     MCCSS office.
 K061 Taking of blood samples in a hospital setting at the request of a
          police officer ....................................................................... 34.80
     Cortical evoked audiometry, multiple frequency (minimum of 4 frequencies in each ear) as
     required by WSIB:
  G153 - technical component .......................................................... 11.35
  G154 - professional component .....................................................   45.85
     Note:
     The technical component of the cortical evoked audiometry service rendered in a hospital is
     payable at 86.10% of the listed fee.

Master, record 2927. Record Layout PDF, page 1.

K05320260401999999990000017450000000000000000000000000000000000000000000000

Auxiliary master fields are preserved as raw scaled values. The linked layout calls them zero-filled, but this edition contains non-zero values. They are not presented as final dollar fees or PDF units.