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INDIAN RIVER COUNTY HEALTH DEPARTMENT FEE SCHEDULE - Effective Oct 1 , 2004 Laboratory Services 0% - A 17% - B 33% - C 50% - D 67% - E 83% = F 1100% - G COST IN-HOUSE LAB - - LAB $0 . 00 $ 1 . 70 $3 . 30 $5.00 $6 . 70 $8 . 30 $ 10 . 00 $ 10 . 00 Contracted Laboratory Services LAB $0 .00 $3 .40 $6.60 $ 10 . 00 $ 13 .40 $ 16 . 60 $20 . 00 $20 .00 NOTE : Tests which exceed a charge of $ 100 .00 will be billed individually on sliding fee scale percentage based on IRCHD cost of lab service . IN and CONTRACTED LAB Fee is for all labs performed at the time of service . Pharmacy - -�--- � -� - Pharmaceutical items will be billed on a per pill basis at IRCHD cost. An itemized pharmaceutical listing is updated weekly and is available by contacting the cashier. Items received from the State Pharmacy as in-kind donation at no cost to IRCHD will not be charged to the patient. Medical Records Fees Copy of Medical Record/per page $ 1 .00 per page for the first 25 pages ; $ .25 each additional a e thereafter. 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. Vital Statistics Fees - - Birth Certificates $ 12 .00 �- Additional Copies $8.00 Death Certificates $ 10 .00 Research Fee (per year) $3.00 Expedite Fee $5.00 1 Overnite Shipment $ 10 . 00 _ 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 . Environmental Health County Fees Well Permit (Potable ) $75.00 Environmental Health Plan Review $75.00 Well Permit (Irrigation ) $50 .00 Environmental Assessment $ 150 .00 Well Permit (2 Sites or more) $ 100 .00 Grease Trap Construction Permit $75 .00 Well Abandoment $0 . 00 _ JGrease Trap Annual Operating Permit $50 . 00 _ Well Permit Construction Variance $ 100 .00 Hazardous Waste (SQG ) Annual Fee $50 .00 Public Supply Well Permit L $250 .00 "After the Fact" OSTDS New System $400 .00 Demolition Permit $50.00 "After the Fact" OSTDS Repair Permit $230 . 00 Demolition Permit $ 100 . 00 Bacteriological Water Sample (Drinking Water) $20 . 00 Reinspection for Demolition Permit $25 .00 Chemical Water Sample $5.060- 25.00 Environmental Health Misc. Lab $20.00 Indoor Air Quality Permit $50 .00 Environmental Health State Fees Please see Attachment VI 11 /2/2004CLFEE2004-05 Page 5 of 7