§665.APPENDIX E. Illinois Department of Public Health Dental Examination Waiver Form

Illinois Department of Public Health

 

DENTAL EXAMINATION WAIVER FORM

 

Please print:

 

Student's Name:   Last                        First                               Middle		Birth Date:   (Month/Day/Year) /      /
Address:   Street                                   City                                       ZIP Code		Telephone:
Name of School:	Grade Level:	Gender:    Male       Female
Parent or Guardian:	Address (of parent/guardian):

 

I am unable to obtain the required dental examination because:

 

q     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).

 

q     My child is enrolled in the free or reduced lunch program and is ineligible for public insurance (medical assistance/ALL KIDS).

 

q     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.

 

q       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

 

(Source:  Added at 33 Ill. Reg. 8459, effective June 8, 2009)