TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER i: MATERNAL AND CHILD HEALTH
PART 665 CHILD AND STUDENT HEALTH EXAMINATION AND IMMUNIZATION CODE
SECTION 665.APPENDIX C ILLINOIS DEPARTMENT OF PUBLIC HEALTH EYE EXAMINATION WAIVER FORM

Section 665.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:   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)