Ill. Admin. Code tit. 77, pt. 665, subpt. F, app E
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 | ____________________ |
Ill. Admin. Code tit. 77, pt. 665, subpt. F, app E