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