Eye Examination Waiver Form printable pdf download

Eye Examination Waiver Form

State of Illinois

Department of Public Health

Eye Examination Waiver Form

Please print:

Student Name ________________________________________________________________________________________________

(Last)

(First)

(Middle Initial)

Birth Date ____________________ Sex _____ School _____________________________________ Grade _______

(Month/Day/Year)

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 the free and reduced lunch program and is ineligible for public insurance (Medicaid/All KIDS).

My child is enrolled in Medicaid/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 see the child and accepts Medicaid/All KIDS.

My child does not have any type of medical or vision/eye care insurance coverage, and there are no low-cost vision/eye clinics in our

community that will see my child.

Signature __________________________________________

Date _______________________

(Source: Added at 32 Ill. Reg. _________, effective ______________)

Printed by Authority of the State of Illinois

IISG08-1048

5/08

H-68

Revised 12/10 Distribution: Health File

Eye Examination Waiver Form