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 E ILLINOIS DEPARTMENT OF PUBLIC HEALTH DENTAL EXAMINATION WAIVER FORM
Section 665.APPENDIX E Illinois Department of Public Health Dental Examination Waiver Form
Illinois Department of Public Health
DENTAL EXAMINATION WAIVER FORM
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.
(Source: Added at 33 Ill. Reg. 8459, effective June 8, 2009)