Washington Apple Health Application - Washington

Medical Marijuana Registry
4300 Cherry Creek Drive South, Denver, CO 80246-1530 303-692-2184
E-mail: medical.m[email protected]ate.co.us
Website:
www.cdphe.state.co.us/hs/medicalmarijuana
MMR1001 – Adult Application – Revised December 2011
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Application Instructions
Colorado Medical Marijuana Registration Cards are available only for Colorado residents being treated for an active, debilitating
medical condition. To apply for a registration card, please submit a complete, accurate application packet as described below. If
your application is incomplete or incorrect, the entire packet will be returned to you. If you make a mistake on a form, please
complete a new form.
Do not write over, white-out or cross-out information. This will void the form.
A complete application packet includes:
1.
An Application for Registration Card completed by you, signed and notarized.
2.
A Physician Certification completed by your doctor.
3. A copy of your Colorado ID. If you do not have a Colorado ID, submit proof of identity and Colorado residency.
4.
A copy of your caregiver’s valid ID, if a caregiver is selected.
5.
A form of payment or a Request for Fee Waiver/Tax Exempt Status form and supporting materials.
1. Medical Marijuana Registry Application
a.
Please complete the entire application. Write or type clearly and neatly.
b.
You may select to have a caregiver or a Medical Marijuana Center. It is not required to have either.
c.
If you are under age 18 or homebound, you may choose both a caregiver and a Medical Marijuana Center.
d.
Complete the physician information. Make sure the physician information on the Medical Marijuana Registry
Application matches the information provided by your doctor on the Physician Certification.
e.
You must sign and date this form in front of a Colorado notary. The date of your signature and the notary’s signature
must be the same.
f. The form cannot be notarized by the patient, the caregiver, the physician or the person who signs the payment.
2. Physician Certification
a.
Your physician must complete and sign the Physician Certification.
b.
The signing physician must be an MD or DO with an active Colorado medical license. Physicians with conditions or
restrictions on their licenses, or out-of-state licenses, are not accepted.
c.
Send in your application packet as soon as possible after the physician signs the Physician Certification. The Registry
must receive your complete, correct application packet within 60 days of the physician’s signature. Application packets
with Physician Certifications more than 60 days old are rejected.
3. Proof of Identity and Residency
a.
Medical Marijuana Registration cards are available only to Colorado residents. You must provide proof of your identity
and residency. Damaged, expired or tampered IDs are not valid.
b.
If you select a caregiver, include a copy of the caregiver’s photo ID with the application packet.
PROOF OF IDENTITY AND COLORADO RESIDENCY
One (1) of the following:
Colorado Driver’s License
Colorado ID
Temporary Colorado Driver’s License
Temporary Colorado ID
Or two (2) of the following:
Minimum of one (1) from the group of IDs below -
Out of State Driver’s License
Out of State ID
Passport, Military ID (copy of front and back), Tribal ID
And a minimum of one (1) from the group below -
Proof of Colorado Employment (paycheck stub/W-2)
Copy of a utility, medical, or cable bill. (The mailing address on all
bills must match address on application. For utility and cable bills, the
service address must be in Colorado.)
i.
All documents must be currently valid when received at the Registry. Damaged, expired, or tampered IDs are not valid.
ii.
Proof of residency materials must be current, within 60 days of the date the Registry receives your paperwork.
iii.
At least one (1) of these documents must show the patient’s date of birth
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