Eye Exam Waiver Form - State Of Illinois
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106.01.10
State of Illinois
Department of Public Health
Eye Examination Waiver Form
Please print:
Student Name _______________________________________________________________________ Birth Date_______________
(Last)
(First)
(Middle Initial)
(Month/Day/Year)
School Name __________________________________________________ Grade Level _________ Gender K Male K 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:
K 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.
K 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.
K 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
IOCI1271-09
6/09
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