Ill. Admin. Code tit. 77, § 665.APPENDIX E
Illinois Department of Public Health
DENTAL 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 dental examination because:
q My child is enrolled in the free or reduced lunch program and is not covered by private or public dental insurance (medical assistance/ALL KIDS).
q My child is enrolled in the free or reduced lunch program and is ineligible for public insurance (medical assistance/ALL KIDS).
q My child is enrolled in medical assistance/ALL KIDS, but we are unable to find a dentist or dental clinic in our community that is able to see my child and will accept medical assistance/ALL KIDS.
q My child does not have any type of dental insurance, and there are no low-cost dental clinics in our community that will see my child.
| Signature | Date |
(Source: Added at 33 Ill. Reg. 8459, effective June 8, 2009)