Ill. Admin. Code tit. 77, § 665.APPENDIX C
State of Illinois
Department of Public Health
EYE EXAMINATION WAIVER FORM
Please print:
| Student's Name: Last First Middle | Birth Date: (Month/Day/Year) | |
| Address: Street City ZIP Code | Telephone: | |
| Name of School: | Grade Level: | Gender: Male Female |
| Parent or Guardian: | Address (of parent/guardian): | |
I am unable to obtain the required eye examination because:
q My child is enrolled in medical assistance/ALL KIDS, but we are unable to find a medical doctor who performs eye examinations or an optometrist in the community who is able to examine my child and accepts medical assistance/ALL KIDS.
q My child does not have any type of medical or vision/eye care coverage, my child does not qualify for medical assistance/ALL KIDS, there are no low-cost vision/eye clinics in our community that will see my child, and I have exhausted all other means and do not have sufficient income to provide my child with an eye examination.
q Other undue burden or a lack of access to an optometrist or a physician who provides eye
| examinations: |
| Signature | Date |
(Source: Added at 33 Ill. Reg. 8459, effective June 8, 2009)