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It allows parents or guardians to formally request an exemption from the mandatory student dental examination requirement under specific financial or access-related conditions. The form collects essential student identification data, demographic information for public health reporting, and requires a declaration of the specific hardship preventing the dental exam, such as lack of insurance or inability to find a participating local provider. It serves as a critical compliance document for schools in Illinois to track student health requirements while ensuring access for those facing systemic barriers. 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request.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},537698,1791689465,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":19,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":8,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":81},3985747859343,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","State of Illinois  \nIllinois Department of Public Health  \nDENTAL EXAMINATION WAIVER FORM  \nPlease print  \n\n| Student’s Name: Last First Middle |  | Birth Date: (Month/Day/Year) |\n| --- | --- | --- |\n| Address: Street City ZIP Code |  |  |\n| Name of School: | ZIP Code | Grade Level: |\n| Parent or Guardian: Last Name First Name |  |  |\n| Select from the below general racial category which most clearly reflects the student’s recognition of his or her community or with which the student most identifies.\u003Cbr>□ White □ Black or African American □ Hispanic or Latino □ Asian\u003Cbr>□ American Indian or Alaska Native □ Native Hawaiian or Pacific Islander □ Two or More Races |  |  |\n\nI am unable to obtain the required dental examination because:  \n􀁆 My child is enrolled in the free and reduced lunch program and is not covered by private or public dental insurance (Medicaid / All Kids) .  \n􀁆 My child is enrolled in the free and reduced lunch program and is ineligible for public insurance (Medicaid / All Kids.  \n􀁆 My child is enrolled Medicaid / 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 Medicaid / All Kids.  \n􀁆 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.  \nParent or Guardian Signature   Date:   \nIllinois Department of Public Health, Division of Oral Health  \n217-785-4899 • TTY (hearing impaired use only) 800-547-0466 • [www.dph.illinois.gov](www.dph.illinois.gov)  \nIOCI 0600-10  \nPrinted by Authority of the State of Illinois Revised 07/2021","cbCaipsy9BWibDIG","https://ap.wps.com/l/cbCaipsy9BWibDIG","pdf",111730,"English","# Student Identification\n## Demographic Information\n# Waiver Justification\n## Reasons for Dental Exam Exemption\n# Certification and Contact Information","[{\"question\":\"Who issues this waiver form?\",\"answer\":\"The form is issued by the Illinois Department of Public Health, Division of Oral Health.\"},{\"question\":\"What are the primary reasons for requesting a waiver?\",\"answer\":\"Waivers can be requested if the student is enrolled in free/reduced lunch programs without insurance, is ineligible for public insurance, or if the family is unable to find a local dentist who accepts Medicaid/All Kids insurance.\"},{\"question\":\"What information is required from the parent or guardian?\",\"answer\":\"The parent or guardian must provide their name, the student's name, school details, grade level, demographic identification, and a signature with the date of the request.\"}]","Dental Examination Waiver Form - State of Illinois | PDF",1791605194]