Forms

Be Prepared Before Your Appointment

To save time for yourself and our staff, as well to avoid additional points of contact during the COVID-19 pandemic, we now offer many of our insurance claim and new patient intake forms online. Simply click the “download” link on the correct form, download the file to your computer, fill it out and hit the “Submit” button at the bottom (you will require the newest version of Adobe Reader to fill the form digitally). Alternatively, you can print it off, fill it out, and either scan it and email it back to us or bring it in to our office with you.

 

If at any time you have questions about which forms to fill out or are having technological difficulties with the forms, please feel free to contact our office via email (southeasteyecare@gmail.com), by phone (306-636-2020), or through the contact form on our website.

 

We hope this information is helpful- we look forward to seeing you at our office!

Insurance Claims

In order for us to direct bill your insurance company, we need your signed consent.  Please complete one of the insurance forms if you have not previously signed it, or if your insurance information has changed.  Please note:  This is for your primary insurance.  In most cases, your insurance company requires you to submit to your primary plan first, then submit the remaining amount to your secondary plan for reimbursement, if applicable.  As well, not all insurance companies and/or plans allow for direct billing.  We must act in accordance with the policies set out by your insurance company.

Insurance Claim Form

New Patients

All new patients will be asked to fill out an intake form prior to their first appointment at our office.  Paper copies are available at our office, which you can fill out when you present for your examination, or you can fill out and submit an electronic copy ahead of time.  Anyone who is 18 years of age (or older) should fill out the Adult form.  Anyone who is under 18 (aged 0-17) should have the Child form completed.

 

Please note:  Any patients who have turned 18 since their last appointment at our office will be required to fill out the Adult form (even if they have previously filled out the Child form), and patients who have not been seen for an appointment in over 5 years will be asked to update their information using the appropriate form, as well.

Adult Intake Form

Child Intake Form

Contact Lenses

Both adults and children should fill out the Contact Lenses intake form if they currently wear contact lenses.  (This is in addition to either the Adult or Child intake form.)  You do not need to fill out the Contact Lenses form if you have discontinued contact lens wear.

 

To place an order or get a quote for new contact lenses, please complete the “Contact Lens Order Form” and submit it to our office. A South East Eyecare representative will either call or email you back as quickly as we can.

Contact Lens Intake Form

Contact Lens Order Form