TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER i: MATERNAL AND CHILD HEALTH
PART 665 CHILD HEALTH EXAMINATION CODE
SECTION 665.APPENDIX C ILLINOIS DEPARTMENT OF PUBLIC HEALTH EYE EXAMINATION WAIVER FORM
Section 665.APPENDIX C Illinois Department of Public Health Eye Examination Waiver Form
State of Illinois
Department of Public Health
EYE EXAMINATION WAIVER FORM
I am unable to obtain the required eye examination because:
q 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.
q 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.
q Other undue burden or a lack of access to an optometrist or a physician who provides eye
(Source: Added at 33 Ill. Reg. 8459, effective June 8, 2009)