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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

Eye Examination Waiver Form

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