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INDIAN RK/ER COUNTY HEALTH DEPARTMENT FEE SCHEDULE — IN-HOUSE LAB LAB $0.00 $4.251 $8.25 1 $12.01 $16.75 $20.75 $25.00 NO CHANGE Contracted Laboratory Services LAB $0.00 $5.95 $11 -SSI $17.S01 $23.45 I $29.05 $35.00 NO CHANGE NOTE: Tests which exceed a charge of $100.00 will be billed individually on a sliding fee scale percentage based on IRCHD cost of lab service IN-HOUSE and CONTRACTED LAB Fee Is for all labs performed at the time of service. All Lab fees will be charged in addition to office visits on a sliding fee scale as above. Miscellaneous Fees General Health Consultation - private facilities and agencies $SS.00 NO CHANGE Smoking Cessation - group setting $25.00 per client NO CHANGE Notary Public Fee $15.00 NO CHANGE Return Check Service Charge $15.00 or 5% of the face amount of the check, draft or order, whichever is greater not to exceed $150.00. (S. 215.34(2), F.S.) I (DOHP 56-66-08 - AR Policy) Special reports (Physician's narrative, insurance forms, or review of medical records by physician) $25.00 CHA Records Fees 7 Copy of Medical Record/per page $0.15 per page and an additional $.05 for double sided copies plus cost of postage N mailed. Large scale copying requets requiring extensive clerical assistance will be subject to an $10.00 administration fee In addition to the above stated fee per FL Statute 119.07. NOTE: Florida Statutes regarding release of medical records must be met prior to release of medical records to any source. No fees are charged to physician offices/other medical agents with the understanding that IRCHD will also be exempt from such payment. 680 School Form / Copy of immunization on Record Knot processed at the same time of immunization Pharmaceutical Services The charges to clients for all items purchased by and under the purview of the Health Department shall be predicated upon the basis of actual costs plus $10.00 fee for each Item purchased on a sliding fee basis. Insulin and Epilepsy medications an be provided at no charge if residents meet financial screening eligibility criteria. Vital Statistics Fees CY 18-19 Fee Birth Certificates (computer) $12.00 NO CHANGE Additional Copies (computer) $10.00 NO CHANGE Death Certificates $12.00 NO CHANGE Plastic Sleeve $5.00 NO CHANGE Research Fee (per year) $3.00 NO CHANGE Expedite Fee $5.00 NO CHANGE Overnight Shipment $15.00 NO CHANGE Birth Certificates are provided free of charge to the following only: Children & Families Case Workers who are Involved in a custody case. Case Worker must present proper ID, completed application request and copy of the signed court petition. Only one certified copy will be provided per six (6) month period. Paye 4 of 7 7/11/2018