77 Ill. Adm. Code 665.APPENDIX E
E Illinois Department of Public Health Dental Examination Waiver Form
Section 665.APPENDIX EÂ Â Illinois Department of Public
Health Dental Examination Waiver Form
Illinois
Department of Public Health
DENTAL
EXAMINATION WAIVER FORM
Please print:
Student's Name:
Last                      Â
First                              Middle
Birth Date:
(Month/Day/Year)
/Â Â Â Â Â /
Address:
Street                                 Â
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