Illinois Administrative Code
Title 77 - PUBLIC HEALTH
Part 665 - CHILD AND STUDENT HEALTH EXAMINATION AND IMMUNIZATION CODE
Subpart F - EYE EXAMINATION
Appendix E - Illinois Department of Public Health Dental Examination Waiver Form

Universal Citation: 77 IL Admin Code ยง E
Current through Register Vol. 48, No. 12, March 22, 2024

Illinois Department of Public Health

DENTAL 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 dental examination because:

[] 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).

[] My child is enrolled in the free or reduced lunch program and is ineligible for public insurance (medical assistance/ALL KIDS).

[] 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.

[] 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

____________________

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