Request Access to Eye Health Manager

To request Online Access to Eye Health Manager, please complete the request form. A username and password will be emailed to your office within 2 business days.

Provider Name *

Office Name *

Office Contact Name *

Tax ID *

Phone *

Email *

Address

City

State

Zip Code

* Check or deposit information is required for your protection to ensure only authorized users obtain access to Eye Health Manager. It may be found on a recent Explanation of Payment (EOP)

Recent check number or EFT payment amount *