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    Medical Marijuana - Applicationform

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    420
    This document is a registration form for the Montana Medical Marijuana Program. It requests information from qualifying patients such as name, date of birth, address, and contact details. If the patient is a minor, it requires that a custodial parent or legal guardian is listed as the primary caregiver. It outlines requirements for both patients and caregivers including signatures agreeing to terms and payment of a $100 registration fee. The form requests this information to comply with the registration requirements of the Montana Medical Marijuana Act.

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    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Medical Marijuana - Applicationform

    Uploaded by

    420
    714 views2 pages
    This document is a registration form for the Montana Medical Marijuana Program. It requests information from qualifying patients such as name, date of birth, address, and contact details. If the patient is a minor, it requires that a custodial parent or legal guardian is listed as the primary caregiver. It outlines requirements for both patients and caregivers including signatures agreeing to terms and payment of a $100 registration fee. The form requests this information to comply with the registration requirements of the Montana Medical Marijuana Act.

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    Medical Marijuana - applicationform

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    This document is a registration form for the Montana Medical Marijuana Program. It requests information from qualifying patients such as name, date of birth, address, and contact details. If the patient is a minor, it requires that a custodial parent or legal guardian is listed as the primary caregiver. It outlines requirements for both patients and caregivers including signatures agreeing to terms and payment of a $100 registration fee. The form requests this information to comply with the registration requirements of the Montana Medical Marijuana Act.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    714 views2 pages

    Medical Marijuana - Applicationform

    Uploaded by

    420
    This document is a registration form for the Montana Medical Marijuana Program. It requests information from qualifying patients such as name, date of birth, address, and contact details. If the patient is a minor, it requires that a custodial parent or legal guardian is listed as the primary caregiver. It outlines requirements for both patients and caregivers including signatures agreeing to terms and payment of a $100 registration fee. The form requests this information to comply with the registration requirements of the Montana Medical Marijuana Act.

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    NEW APPLICATION FORM

    Registration for the Montana Medical Marijuana Program

    Instructions: Please complete all information to comply with the registration requirements of the Montana Medical Marijuana
    Act. If applicant is a minor (under 18), the custodial parent or legal guardian with responsibility for health care decisions must be listed
    as the Primary Caregiver and the information requested on the back of this form must be completed. List your current Montana Drivers
    License number or your Montana State Identification Card number if applicable and your Social Security Number. Please type or print
    legibly.

    QUALIFYING PATIENT INFORMANTION (REQUIRED)

    NAME (LAST, FIRST, M.I.): ________________________________________________ ________ _MALE___FEMALE____

    DATE OF BIRTH: ______ _______MT DRIVERS LICENSE OR MT STATE ID #___ __ ____ _______SSN_______________________

    MAILING ADDRESS: __________________________________COUNTY__ ________ PHONE NUMBER_____________________

    CITY: __________________________________STATE_______ZIP CODE___________EMAIL ADDRESS__________________________


    (OPTIONAL)

    CAREGIVER (IF APPLICABLE)

    NAME (LAST, FIRST, M.I.): ________________________________________________ __________________MALE___ _FEMALE____

    DATE OF BIRTH: ______ _______MT DRIVERS LICENSE OR MT STATE ID #__ ____ ____ _______SSN______________________

    MAILING ADDRESS:___ ______ __________ _ COUNTY_____________________PHONE NUMBER__________________

    CITY: __________________________________STATE_______ZIP CODE___________EMAIL ADDRESS__________________________


    (OPTIONAL)

    NEW REGISTRATION FEE (REQUIRED)


    The registration fee for a NEW application is $100.00 and is non refundable unless the applicant is denied.
    Enclose your check or money order made payable to “DPHHS /LICENSURE BUREAU

    SIGNATURE & DATE REQUIRED

    QUALIFYING PATIENT SIGNATURE: ___________________________________________DATE: ____________________


    “QUALIFYING PATIENT” Means a person who has been diagnosed by a physician as having a Debilitating Medical Condition.

    CAREGIVER SIGNATURE: ____________________________________________________DATE: ___________________


    As the CAREGIVER for the Qualifying Patient named above, I agree to provide Medical Marijuana only to this Qualifying Patient.
    I have never been convicted of a felony drug offense. I understand that I am subject to a mandatory background check.

    (OVER)
    DECLARATION OF PERSON RESPONSIBLE FOR MINOR

    INSTRUCTIONS: Complete all information in order to comply with the registration requirements of the Montana Medical
    Marijuana Act. This portion is required in addition to the patient application portion if the qualifying patient is under 18 years of age.

    1. I am the __Custodial Parent or __Legal Guardian with responsibility for health care decisions for:

    _______________________________________________________________________
    MINORS NAME
    2. The applicant’s attending physician has explained to the minor and me the potential risk and benefits of the medical use of marijuana.
    3. I consent to the use of marijuana by the applicant for medical purposes.
    4. I agree to serve as minor’s designated primary caregiver; AND
    5. I agree to control the acquisition of marijuana and the dosage and frequency of use by the minor.

    NAME (LAST, FIRST, M.I.): ________________________________________________ _______________MALE FEMALE______

    DATE OF BIRTH: ______ _______MT DRIVERS LICENSE OR STATE ID #___ ____ ____ _______SSN_______________________

    MAILING ADDRESS: ______________________________________________________TELEPHONE NUMBER_____________________

    CITY: __________________________________STATE_______ZIP CODE___________EMAIL ADDRESS__________________________


    (optional)

    SIGNATURE OF CUSTODIAL PARENT OR LEGAL GUARDIAN: ___________________________________________________________

    MAIL APPLICATION FORM TO: DPHHS / QUALITY ASSURANCE DIVISION


    LICENSURE BUREAU
    PO BOX 202953
    HELENA MT 59620-2953

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