Practice Tools & Form Examples

Alaska Medical Marijuana Application Packet

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Medical Marijuana Application Packet

Arizona Medical Marijuana – Qualifying Patient Checklist

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Print out and review this checklist prior to submitting your Qualifying Patient Application in the ADHS online system.

Arizona Medical Marijuana – Qualifying Patient Under the Age of 18 Checklist

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Print out and review this checklist prior to submitting your Qualifying Patient Application in the ADHS online system.

Arizona Medical Marijuana Program – Caregiver Attestation Form

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This attestation form needs to be completed and submitted when applying for a certification or a registry identification card.

Arizona Medical Marijuana Program – Custodial Parent/Legal Guardian Attestation Form

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This Attestation form needs to be completed and submitted when applying for a certification or a registry identification card.

Arizona Medical Marijuana Program – Designated Caregiver Checklist

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Print out and review this checklist prior to submitting your Qualifying Patient Application in the ADHS online system.

Arizona Medical Marijuana Program – Physician Certification Form

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If a physician would like to recommend medical marijuana to a qualifying patient, the physician must first certify that the patient has one of the "debilitating medical conditions" listed in A.R.S. §36-2801. 

Arizona Medical Marijuana Program – Reviewing Physician Certification Form

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If the qualifying patient is under the age of 18 a reviewing certification, provided by a different physician, is required. The reviewing physician must review the qualifying patient's medical records and also recommend medical marijuana to the qualifying patient. 

Arizona Patient Attestation Form

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This Attestation form needs to be completed and submitted when applying for a certification or a registry identification card.

Arizona Qualified Patient Request to Add or Replace Caregiver Form

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This form needs to be completed and submitted when a qualified patient is adding or replacing his or her designated caregiver.

Business Associate Agreement Template

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This Privacy Agreement ("Agreement"), is effective upon signing this Agreement and is entered into by and between Insert Clinic Name ("Covered Entity") and VENDOR (the "Business Associate").

California – Medical Marijuana Program Appliation/Renewal

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Medical Marijuana Program Application/Renewal (English version)

California – Medical Marijuana Program Appliation/Renewal

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Medical Marijuana Program Application/Renewal (Spanish version)

California – Medical Marijuana Program Denial Appeals Application

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Medical Marijuana Program Denial Appeals Application form (Spanish version)

California – Medical Marijuana Program Denial Appeals Application

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Medical Marijuana Program Denial Appeals Application form (English version)

California – Medical Marijuana Program Monthly Remittance Form

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Instructions:Within 30 calendar days after the end of the remittance month, please submit the following identification card activity information along with a check or money order for the California Department of Public Health’s (CDPH) portion of the fees collected.

California – Medical Marijuana Program Written Documentation Of Patient’s Medical Records

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Note to Attending Physician: This is not a mandatory form. If used, this form will serve as written documentation from the attending physician, stating that the patient has been diagnosed with a serious medical condition and that the medical use[...]

California – Medical Marijuana Program Written Documentation Of Patient’s Medical Records

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Note to Attending Physician: This is not a mandatory form. If used, this form will serve as written documentation from the attending physician, stating that the patient has been diagnosed with a serious medical condition and that the medical use[...]

Caregiver Change Form

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Please download this form to find instructions for how to change caregivers for the Michigan Medical Marijuana Program.

Colorado – Change Request Form

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Change request form with information.

Colorado – Physician Certification Form

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This physician certification is a recommendation and does not constitute a prescription for medical marijuana.

Colorado – Proof of Identity and Residency Waiver

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This waiver must be submitted with your application and is ONLY valid for one (1) year.

Colorado – Provider Information Update Form

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Physicians and caregivers may submit this form to update contact information in the Registry's database.

Colorado – Provider Signature Revocation Form

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By submitting this form, your name and contact information will be removed from the patient's current record.

Connecticut Change of Caregiver/Legal Guardian Form

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This form is to address a change in Caregiver/Legal Guardian.

Connecticut Change of Records Form

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A qualifying patient or primary caregiver must report any changes in their application within 5 business days of such change.

Connecticut Dispensary Change Form

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A qualifying patient or primary caregiver may change the patient's designated dispensary facility.

Connecticut Physician Decertification Form

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You may only use this form to decertify a patient if you were the patient's certifying physician.

Connecticut Report Lost or Stolen Card Form

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A qualifying patient or primary caregiver must report their lost or stolen registration card.

Delaware Fee Waiver Request Form

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Low Income Charge Request Form to waive fee.

Delaware Medical Marijuana Pediatric Patient Application

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Medical Marijuana Pediatric Patient Application

Florida Compassionate Use Change, Replacement, or Surrender Request Instructions

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In order to change, replace or surrender your Compassionate Use Registry Identification Card, complete the Cardholder Information section and applicable section(s) of this form."

Florida Compassionate Use Patient’s Guide

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Office of Compassionate Use Low-THC Cannabis & Medical Cannabis Patient's Guide

Florida Compassionate Use Physicians Requirements Info Sheet

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Physicians Requirements Info Sheet for the Compassionate Use Registry

Florida Compassionate Use Quick Facts Sheet

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Quick Facts Sheet about the Compassionate Use Registry

Florida Compassionate Use Registry – Users Guide For Law Enforcement Users

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Users Guide For Law Enforement Users Compassionate Use Registry

Florida Compassionate Use Registry Identification Card Application

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Instructions for Qualified Patients - Compassionate Use Registry Identification Card Application

Florida Compassionate Use Registry Identification Card Legal Representative Application

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Instructions for Legal Represntative- Compassionate Use Registry Identification Card Application

Florida Compassionate Use Registry Legal Representatives User Guide

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Legal Representatives User Guide for the Compassionate Use Registry Online

Florida Compassionate Use Registry Patient User Guide

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Patient User Guide for the Compassionate Use Registry Online

Florida Compassionate Use Registry Physician User Guide

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Physician User Guide for the Compassionate Use Registry Online

Florida Initial Low-THC Treatment Plan Form

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The Act authorizes specific physicians to order low-THC cannabis for use by specific patients.

Hawaii – Change Form Packet Checklist

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A change form packet is required for the following: Replacement card, Update information, or void request.

Hawaii – Electronic Signature Agreement

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Each physician must complete this electronic signature agreement and return the original copy to DOH.

Hawaii – Medical Marijuana Registry Program Change Form

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Change form packet. Only the registered applicant/patient can request changes.

Hawaii – Patient Application System – Detailed Instructions

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How to complete an application in the DOH 329 registry patient application system. Detailed instructions for patients and their caregivers.

Hawaii – Patient Application System Overview of Changes to DOH 329 Registry

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Overview of Changes to the DOH 329 Registry - Patient Application System. For certifying Physicians.

Hawaii – Patient Initiated Application Process

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DOH 329 Registry - Patient Initiated Application - Detailed Instructions for certifying Physicians.

Hawaii – Physician Initiated Application Process

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DOH 329 Registry - Physician Initiated Application - Detailed Instructions for certifying Physicians.

Hawaii – Request to Void Patient’s Registration Card

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In the unfortunate event that a patient has passed, the certifying physician is required to submit the request to void patient's registration card.

Illinois – Medical Cannabis Patient Application

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Medical Cannabis Patient Application information online.

Illinois – Medical Cannabis Pilot Program

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Welcome to the State of Illinois Medical Cannabis Pilot Program eLicense System.

Illinois – Registry Card Application Fees

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Application Fees for Qualifying Patients and Designated Caregivers.

Maine – Change/Re-Issue Form

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Maine Medical use of Marijuana Program - Change information/Re-Issue form.

Maine – Designation Form

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Maine Medical use of Marijuana Program - Designation Form. A patient may designate either a primary caregiver or a dispensary to cultivate.

Maine – Employee Application

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Maine Medical use of Marijuana Program - Employee Application

Maine – Primary Caregiver Application

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Maine Medical use of Marijuana Program - Primary Caregiver Application

Maine – Temporary Primary Caregiver Designation

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Maine Medical use of Marijuana Program - Temporary Primary Caregiver Designation

Minnesota – A Primer for Health Care Professionals

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Intractable Pain Certification in the MN Medical Cannabis Program.

Minnesota – Department Of Health – Office of Medical Cannabis

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Important information and warnings about using medical cannabis.

Minnesota – Designated Caregiver Background Check

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Designated Caregiver Background Check Informed Consent.

Minnesota – Health Care Practitioner Guidance

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Health Care Practitioner Guidance for Minnesota's Medical Cannabis Program

Minnesota – Health Care Practitioner Patient Certification Acknowledment/Consent/Disclosure

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Health Care Practitioner Patient Certification Acknowledment/Consent/Disclosure form.

Minnesota – Health Care Practitioner Registration Acknowledment/Consent/Disclosure

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Health Care Practitioner Registration Acknowledment/Consent/Disclosure form.

Minnesota – Medical Cannabis A Patient’s Guide

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This patient guide gives information on how to register, receive and certify for the medical cannabis program.

Minnesota – Medical Cannabis Disposal Methods

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Medical Cannabis Disposal Methods for Registered Patients and Caregivers.

Minnesota – Patient Acknowledgment Form

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Patient E-Mail and Acknowledgment form. Bring this form to your practitioner.

Minnesota – Practitioner Guide

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Health Care Practitioner Navigator I: Your Role and Responsibilities.

Minnesota – Practitioner Guide 2

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Health Care Practitioner Navigator II: Register Yourself and Certify Patients.

MMMP Application Packet

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Please download this packet to find instructions for apply to the Michigan Medical Marijuana Program.

MMMP Minor Application Packet

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Please download this packet to find instructions for how minors apply for the Michigan Medical Marijuana Program.

Montana Marijuana Program

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Marijuana program information page.

Montana Marijuana Program – Change Request Form

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Change request form must be used to sumbit any information changes to the department.

Montana Marijuana Program – Landlord Permission Form

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Cardholder (patient) applicants and provider applicants must use this form to obtain permission from their landlord if they will cultivate and/or manufacture marijuana at a property that is rented or leased.

Montana Marijuana Program – Minor Registered Cardholder (Patient) Application

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A parent or legal guardian of a minor applicant must complete all sections of this form in order for the minor to apply for the Montana Marijuana Registry.

Montana Marijuana Program – Physician Statement for a Debilitating Medical Condition

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Registered cardholder applicants with a debilitating medical condition must use this form when applying for the Montana Marijuana Program registry.

Montana Marijuana Program – Physician Statement for Minors

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Minor registered cardholder applicants with a chronic pain diagnosis must use this form when applying for the Montana Marijuana Program Registry.

Montana Marijuana Program – Provider/Marijuana Infused Products Provider (MIPP) Application

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Complete all sections of this form in order to comply with the registration requirements of the Montana Marijuana Program.

Nevada – Certificate Renewal Form

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Renewal Application Form for Medical Marijuana Establishment (MME) Registration Certificates.

Nevada – Fingerprint Background Waiver

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Fingerprint Background Waiver form

Nevada – Fingerprint Instructions for Out-Of-State Applicants

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Fingerprint Instructions for Out-Of-State Applicants

Nevada – Provisional Registration Renewal Form

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Renewal Application Form for Medical Marijuana Establishment (MME) Provisional Registration Certificates.

New Hampshire – Application For the Therapeutic Use of Cannabis Qualifying Patient

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A qualifying patient must fill out this application for the Therapeutic Use of Cannabis.

New Hampshire – Caregiver Designation/Removal Form

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This form is to be completed if you need to designate a caregiver or remove a caregiver.

New Hampshire – Change of Information/Lost Card Form

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This form should be filled out if there is a change in your information or you have lost your card.

New Hampshire – Criminal History Record Information Authorization

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This form is from Designated Caregivers and ATC Agents ONLY.

New Hampshire – Deisgnated Caregiver Application

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Application for the Thereputic Use of Cannabis Designated Caregiver.

New Hampshire – Designated Caregiver Attestation Form

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Designated Caregiver's Attestation of No Felony Conviction Form.

New Hampshire Therapeutic Cannabis Program – Providers Written Certification

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Written Certification for the Therapeutic Use of Cannabis to be completed by a medical provider.

New Mexico HIPAA Authorization Form

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Authorization to disclose health information form.

New Mexico Information Change or Replacement Card

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This form is used to update your contact information that has changed, or to receive a replacement medical cannabis ID card.

New Mexico Patient Application

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Patient application form for new enrollment and re-enrollments.

New Mexico Personal Production License Application

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Personal production license application form - Medical cannabis can only be grown at property or residence of the licensed qualified patient.

New York Patient Certification Instructions

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This document covers the steps for how patients get certified for New York's medical marijuana program. Prior to issuing a certification, practitioners must consult the Prescription Monitoring Program (PMP) Registry to review their patient's controlled substance history.

New York Practitioner Registration Instructions

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This document summarizes the steps that practitioners must take to register with the New York State Department of Health's (NYSDOH) Medical Marijuana Program. A practitioner must meet each of the following requirements with this document prior to registering.

Oregon Medical Marijuana Program – Attending Physician’s Statement

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Please complete all sections of this form in order to comply with the registration requirements of the Oregon Medical Marijuana Act. Must be signed by the Physician within 90 days of application date.

Oregon Medical Marijuana Program – Declaration of Person Responsible for a Minor to Participate form.

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Complete all required information in order to comply with the registration requirements of the Oregon Medical Marijuana Act.

Oregon Medical Marijuana Program Application

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Please read instructions and fee information on back BEFORE filling this form out.

PA Department of Health Safe Harbor Physician Form

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A Pennsylvania Safe Harbor Letter is available to parents, legal guardians, caregivers, and spouses of a minor under the age of 18 who suffers from one of the seventeen serious medical conditions defined in the Medical Marijuana Act.

Patient Change Form

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Please download this form to find instructions for the release of disclosure information for the Michigan Medical Marijuana Program.

Patient Focused Certification (PFC)

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Introducing ASA's independent certification program for medical cannabis industries, Patient Focused Certification (PFC).

Release for Disclosure of Information Form

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Please download this form to find instructions for the release of disclosure information for the Michigan Medical Marijuana Program.

Rhode Island Medical Marijuana Patient Application

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Instructions and Application for Initial Registration as a Medical Marijuana Patient.

Rhode Island Medical Marijuana Patient Information Change Form

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This form is to be used by patients only for change of information.

Rhode Island Medical Marijuana Practitioner Form

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Please complete patient information and have your practitioner complete all other sections of this form in order to comply with registration requirements of Rhode Island Medical Marijuana Act.

Vermont – Cardholder Information Notification Form

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This form is to be completed by the cardholder if their information has changed.

Vermont – Complete Registered Patient Application Packet

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Complete registered patient application packet includes the patient application and health care professional verification form.

Vermont – Dispensary Selection Information

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The information on this page contains important provisions to aid patients when applying for a registry identification care with the Vermont Marijuana Registry.

Vermont – Registered Caregiver Application Form

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A registered caregiver is a person designated by the registered patient's sole preference.

Washington – Medical Marijuana Authorization Guidelines

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This guideline pertains to shared professional practice standards expected of all healthcare professionals who authorize medical marijuana under Washington State law.

Washington – Medical Marijuana Consultant Certificate Application Packet

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Certified consultants may provide consultant services only while employed at a retail store with a medical endorsement. Certificate holders may not work as medical marijuana consultants until July 1, 2016.

Washington – Social Security Number Notification Form

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This form should be filled out by a medical marijuana consultant. Certified consultants may provide consultant services only while employed at a retail store with a medical endorsement. Certificate holders may not work as medical marijuana consultants until July 1,[...]

Washington State Medical Marijuana Authorization Form

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This form must be filled out by the patient and designated provider.





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