Ill. Admin. Code tit. 77, pt. 665, subpt. F, app C

Current through Register Vol. 49, No. 2, January 10, 2025

Appendix C - Illinois Department of Public Health Eye Examination Waiver Form

State of Illinois

Department of Public Health

EYE EXAMINATION WAIVER FORM

Please print:

Student's Name: LastFirstMiddle		Birth Date: (Month/Day/Year)
Address: StreetCityZIP Code		Telephone:
Name of School:	Grade Level:	Gender: MaleFemale
Parent or Guardian:	Address (of parent/guardian):

I am unable to obtain the required eye examination because:

[] 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.

[] 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.

[] Other undue burden or a lack of access to an optometrist or a physician who provides eye

examinations: __________________________________________________

Signature _______________________________ Date __________________

Ill. Admin. Code tit. 77, pt. 665, subpt. F, app C

Added at 33 Ill. Reg. 8459, effective June 8, 2009