Actuel Page 1 Page 2 Aperçu 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 902-213-2970. Identification I am submitting this form as the child's: - Sélectionner -Parent/GuardianOptician Enter your contact information as the child's parent/guardian in the fields below. Enter your contact information as the child's optician and include the name of the business to be reimbursed in the fields below. Business/Organization Name Prénom Initiale Nom Adresse 1 Adresse 2 Ville, municipalité, communauté Province Code postal Exemple : C1B 0X1 ou 12345 Pays Numéro de téléphone Exemple : 902-555-5555 Adresse courriel Numéro de carte-santé (NCS) Entrez les 8 chiffres de la carte-santé de l’Î.-P.-É.