Eye Examination Waiver Form

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Eye Examination Waiver Form
State of Illinois
Illinois Department of Public Health
Please print:
Student Name _____________________________________________________________ Birth Date ______________
(Last)
(First)
(Middle Initial)
(Month/Day/Year)
School Name __________________________________________ Grade Level________ Gender:  Male  Female
Address __________________________________________________________________________________________
(Number)
(Street)
(City)
(ZIP Code)
Phone___________________________
(Area Code)
Parent or Guardian _________________________________________________________________________________
(Last)
(First)
Address of Parent or Guardian ________________________________________________________________________
(Number)
(Street)
(City)
(ZIP Code)
I am unable to obtain the required vision 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 to a physician who provides eye examinations:
________________________________________________________________________________________________
________________________________________________________________________________________________
Signature ___________________________________________
Date _______________________
(Source: Added at 32 Ill. Reg. _________, effective ______________)
Printed by Authority of the State of Illinois
IOCI 13-378

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