Current Page 1 Page 2 Preview Personal health information on this form is collected by Health PEI for the purposes of your care and for other purposes permitted by the Health Information Act, including the planning and management of health services. Your information will be collected, used and disclosed only as permitted by law. For more information, you may contact the Vision Care program office at 902-213-2790. Identification I am submitting this form as the child or children's: - Select -Parent/GuardianOptometristOptician Enter your contact information as the child or children's parent/guardian in the fields below. Enter your contact information as the child or children's optometrist or optician and include the name of the business to be reimbursed in the fields below. Business/Organization Name First Name Middle Initial Last Name Address 1 Address 2 City, Town, or Community Province Postal Code For example C1B 0X1 or 12345 Country Telephone Number For example 902-555-5555 Email Address Personal Health Number (PHN) Enter the 8-digits from the PEI health card