"Application for Initial Registration as a Medical Marijuana Patient" - Rhode Island

Application for Initial Registration as a Medical Marijuana Patient is a legal document that was released by the Rhode Island Department of Health - a government authority operating within Rhode Island.

Form Details:

  • Released on February 25, 2019;
  • The latest edition currently provided by the Rhode Island Department of Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Rhode Island Department of Health.

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Download "Application for Initial Registration as a Medical Marijuana Patient" - Rhode Island

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***FOR OFFICE USE ONLY***
Checklist
Approved By:
Patient App. & Fee $50.00 or Fee
$25.00 with Proof of Medicaid, SSI,
Date of Approval:
SSDI or Veterans’ Disability
Proof of RI Residency
Registration Number:
Practitioner Form
Applicant ID #:
Autism Diagnosis Form (if applicable)
Minor Form (If applicable)
Receipt #:
Natural PersonCaregiver
Authorized Purchaser
Rhode Island
Center for Professional Licensing
Room 105A - 3 Capitol Hill
Providence, RI 02908-5097
Instructions and Application For
Initial Registration As A
Medical Marijuana Patient
Have you EVER held a registration as a medical marijuana patient in Rhode Island?
Yes
No
If yes, DO NOT Complete this initial application. Please email
doh.mmp@health.ri.gov
to obtain the correct
renewal application.
Applicant - Print Name (First/MI/Last)
DO NOT REMOVE PAGES FROM THE APPLICATION
PLEASE SEND ALL PAGES OF THIS APPLICATION WITH PAYMENT
In order to ensure timely delivery and avoid unexpected delays, please send
your ORIGINAL completed application by regular US mail.
Photocopies not accepted.
Phone: (401) 222-3752
TTY/TDD: (800) 745-5555
Fax: (401) 222-1745
Revised 02/25/2019 jcp
***FOR OFFICE USE ONLY***
Checklist
Approved By:
Patient App. & Fee $50.00 or Fee
$25.00 with Proof of Medicaid, SSI,
Date of Approval:
SSDI or Veterans’ Disability
Proof of RI Residency
Registration Number:
Practitioner Form
Applicant ID #:
Autism Diagnosis Form (if applicable)
Minor Form (If applicable)
Receipt #:
Natural PersonCaregiver
Authorized Purchaser
Rhode Island
Center for Professional Licensing
Room 105A - 3 Capitol Hill
Providence, RI 02908-5097
Instructions and Application For
Initial Registration As A
Medical Marijuana Patient
Have you EVER held a registration as a medical marijuana patient in Rhode Island?
Yes
No
If yes, DO NOT Complete this initial application. Please email
doh.mmp@health.ri.gov
to obtain the correct
renewal application.
Applicant - Print Name (First/MI/Last)
DO NOT REMOVE PAGES FROM THE APPLICATION
PLEASE SEND ALL PAGES OF THIS APPLICATION WITH PAYMENT
In order to ensure timely delivery and avoid unexpected delays, please send
your ORIGINAL completed application by regular US mail.
Photocopies not accepted.
Phone: (401) 222-3752
TTY/TDD: (800) 745-5555
Fax: (401) 222-1745
Revised 02/25/2019 jcp
Requirements for Patients
Must be a Rhode Island resident and must submit proof of residency. The following are acceptable documents: copy
of a RI Driver’s License, RI State ID, vehicle registration, voters registration, correspondence from another state
agency with a current date or a current car insurance bill. Your name current address and current date must appear
on the document you submit as proof of residency. NOTE: You are required to come in to have your photograph
taken for the ID card, at which time you must present a current RI Driver’s license or RI State I.D. No other form of
ID will be accepted.
Complete and Sign a Patient Form
Submit a Practitioner Form - Practitioner Written Certification Form must be completed and signed by one of the
following practitioner types: Advanced Practice Nurse, Physician Assistant or Physician (MD, DO) licensed to
practice in RI or Physician (MD, DO) licensed to practice in MA or CT.
Submit a non-refundable Application Fee (Check or Money Order, Payable to RI General Treasurer) Fifty
dollars ($50.00) OR Twenty-five dollars ($25.00) if you are a recipient of Medicaid, Supplemental Security Income
(SSI), Social Security Disability Income (SSDI), Federal Railroad Disability benefit. (NOT Social Security or Medi
care) or Veterans’ Disability Photocopy of Medicaid Card, State of Rhode Island “ANCHOR” Medical Assistance
Card, a current letter stating that you are a recipient of Medicaid, SSI, SSDI or Veterans’ Disability. Proof must
accompany the application to be eligible for the reduced fee. Verification of your SSI or SSDI eligibility can be
obtatined at http://www.ssa.gov. Note: If the patient’s physician provides a written statement indicating the patient is
receiving chemotherapy or is Hospice Eligible there is no fee for the patient registration.
You can designate one (1) caregiver and/or one (1) authorized purchaser. The law requires caregivers and autho
rized purchasers to obtain a background check from the National Criminal Information Center (NCIC). In addition,
caregivers or authorzied purchasers can be disqualified for a variety of felony charges, not just felony drug
convictions. (See pages 6 and 7 for application fees and instructions for caregivers and authorized purchasers.)
Requirements for Minor Patients - (Under 18 Years of Age)
I
n addition to the requirements listed above, minor patients MUST designate a custodial parent or legal guardian as
their primary caregiver or authorized purchaser. Additionally, a Minor Form must be completed, signed and submitted
along with the Patient Form as described above.
GENERAL INFORMATION
Please send in all pages of this application together with payment and other required documentation to the address listed
on the front cover of this application. Do not separate or mail pages separately. Application must be ORIGINAL. Photo-
copies will not be accepted.
Please keep a copy of your application. The Department does not make copies of applications for the public.
The application process takes 2-4 weeks from the date it is accepted in this office. Applications received that are incom-
plete will be returned to the patient and the processing time will start over. For confidentialtiy purposes information regard-
ing application status will NOT be given over the phone. Once you are approved you will receive a letter to come in for your
photograph.
If you are intending on growing marijuana in the next year you must contact the Department of Business Regulations at
401-462-9661 or visit their website at www.dbr.ri.gov.
Once you are issued the registration you can use any of the three compassion centers in Rhode Island.
Rules and Regulations for the program and forms are available on our website at:
http://www.health.ri.gov/healthcare/medicalmarijuana
Changes of Information - (once registered)
After you (and your caregiver and/or authorized purchaser)
receive your registration cards, you can change information by completing a “Change Form”, available online
at the above website. If you have any questions regarding patient, caregiver or authorized purchaser applica
ions please call 401-222-3752 or email doh.mmp@health.ri.gov.
There is a ten-dollar ($10.00) fee to reprint a new card.
Lost Card (s)
Medical Marijuana Program - Page 2
State of Rhode Island - Center for Professional Licensing
“PATIENT FORM”
Refer to the Application Instructions when completing these forms. Type or block print only. Do not use felt-tip pens.
Patient Name
First Name
Middle Name
Last Name
Suffix (i.e., Jr., Sr., II, III)
Patients under 18 years of age MUST designate a custodial parent or legal guardian
Date of Birth
as a caregiver and/or authorized purchaser. Additionally, a Minor Form must be
Day
Year
Month
completed, signed and submitted along with the Patient Form
Home
Address and
1st Line Address (Apartment/Suite/Room Number, etc.)
Contact Info
It is your
Second Line Address (Number and Street)
responsibility to
notify the
City
State
Zip Code
department of all
address chang-
Phone
es.
Email Address (Format for email address is Username@domain e.g. applicant@isp.com)
If you answer Yes to the question below this Email will be shared with whoever is conducting a study
Mailing
Address
1st Line Address (Apartment/Suite/Room Number, etc.)
Second Line Address (Number and Street)
City
State
Zip Code
Do you intend to grow marijuana in the coming year?
Yes
No
401-462-9661 to purchase tags.
If Yes, You must contact DBR at
Are you pregnant or do you plan to become pregnant within the next 12 months?
Yes
No
“This information is requested for data purposes only, and will not be used in the consideration of your application. Answering yes will not result in denial of your application.”
Would you like to be notified of any clinical studies about marijuana’s risk or efficacy?
Yes
No
Practitioner
Name and Ad-
First Name
dress Informa-
tion
Middle Name
Practitioner”
Last Name
means a person
who is licensed
with authority to
Suffix (i.e., Jr., Sr., II, III)
prescribe drugs
pursuant to chapter
1st Line Address (Apartment/Suite/Room Number, etc.)
37, chapters 34, 37
and 54 of title 5 or a
physician licensed
Second Line Address (Number and Street)
with authority to
prescribe drugs in
City
State
Massachusetts or
Zip Code
Connecticut.
Phone
I hereby certify that all of the information provided on this application is true and accurate to the best of my
Patient’s Attes-
knowledge.
tation Signature
and Date
If I am incapable of completing or signing my name to this form, I have authorized my proxy to complete this
form; attest to; and sign this statement. I also agree to notify the Department of Health, Center for Professional
Licensing, Medical Marijuana Program, in writing (use “Change Form”) within ten (10) days of any changes to
the information provided.
Patient’s Signature
Date of Signature
Proxy’s Signature (if applicable)
Date of Signature
Medical Marijuana Program - Page 3
Department of Health
Center for Professional Licensing
Room 105A - 3 Capitol Hill
Providence, RI 02908-5097
401-222-3752 - www.health.ri.gov/hsr/mmp
PRACTITIONER WRITTEN CERTIFICATION FORM
Instructions: Please complete patient information and have your practitioner complete all other sections of this form in order to comply
with the registration requirements of the Rhode Island Medical Marijuana Act. Please attach this form to the Patient Application Form
and mail the completed forms to the address listed above.
NOTE: This does NOT constitute a prescription for marijuana
Patient Name,
Date of Birth
Full Name
and Phone
Number:
Birth Day
Birth Year
Birth Month
Phone
Practitioner
Name, License
Full Name
Number and
Address Infor-
License Number
mation
1st Line Address (Apartment/Suite/Room Number, etc.)
Second Line Address (Number and Street)
City
State
Zip Code
Phone
Email Address (Format for email address is Username@domain e.g. applicant@isp.com)
These are the ONLY approved qualifying debilitating medical conditions - Check the appropriate box(es):
Cancer or the treatment of this condition. Is the patient receiving chemotherapy?
Yes
No
Practitoner Signature____________________________________
Glaucoma or the treatment of this condition
Positive status for Human Immunodeficiency Virus (HIV) or the treatment of this condition
Acquired immune deficiency syndrome (AIDS) or the treatment of this condition
Hepatitis C or the treatment of this condition
A chronic or debilitating disease or medical condition or its treatment that produces one or more of the following:
(Check all appropriate box(es))
Cachexia or wasting syndrome
Severe, debilitating, chronic pain-(specify)
Severe nausea
Seizures, including but not limited to those characteristic of epilepsy
Severe and persistent muscle spasms, including but not limited to, those characteristic of multiple sclerosis or
Crohn’s disease
Agitation related to Alzheimer’s Disease
Post Tramatic Stress Disorder (PTSD) - Patient must be 18 years or older
Autism Spectrum Disorder - Practitioner must complete Page 5 if this diagnosis is checked.
Comments:
Practitioner” means a person who is licensed with authority to prescribe drugs pursuant to chapter 37, chapters 34, 37 and
54 of title 5 or a physician licensed with authority to prescribe drugs in Massachusetts or Connecticut.
I hereby certify that I am a practitioner as defined above. I have a practitioner-patient relationship with the qualifying
patient and have completed a full assessment of the patient’s medical history. The above-named patient has been
diagnosed with a debilitating medical condition as listed above. Marijuana used medically may mitigate the symptoms
or effects of this patient’s condition. Further, it is my professional opinion that the potential benefits of the medical use of
marijuana would likely outweigh the health risks for this patient.
HOSPICE ONLY: If this patient is eligible for hospice care, the physician must sign here otherwise sign below.
Practitioner Signature (patient eligible for Hospice)________________________________________________________
Practitioner’s Printed Name:
Practitioner’s Signature:
Date of Signature:
Medical Marijuana Program - Page 4
This form is to be completed by the Attending Practitioner.
Department of Health
Center for Professional Licensing
Room 105A - 3 Capitol Hill
Providence, RI 02908-5097
401-222-3752 - www.health.ri.gov/hsr/mmp
PRACTITIONER WRITTEN CERTIFICATION FORM
FOR USE WITH AUTISM SPECTRUM DISORDER DIAGNOSIS
NOTE: A patient who has been diagnosed with Autism Spectrum Disorder based on diagnostic criteria listed
in DSM-V – Diagnosis Code 299.00 may qualify for registration as a patient in the Rhode Island Medical
Marijuana Program only if the patient presents with one or both the following symptoms. Please check
symptom(s) that apply.
Repetition of self-stimulatory behavior of such severity that the physical health of the
persons with ASD or others is jeopardized, and/or
Avoidance of others or inability to communicate with others to such severity that the
physical health of the person with ASD is jeopardized.
For patients who meet the above diagnostic criteria, the practitioner signing this form is certifying that all of
the following treatment considerations and practices have been met:
I have considered FDA-approved medications for this patient, including the off-label use of the pharmaceu-
tic grade forms of pure CBD, prior to initiating medical marijuana therapy. If use of these medications was
not implemented, I have documented the reason in the patient's medical record. __________ (Initial here)
If this patient is a minor, I have consulted with a pediatric sub-specialist in child psychiatry, pediatric neu-
rology, or developmental pediatrics prior to signing this form, and the results of that consult is documented
in the patient's medical record. _________ (Initial here)
I hereby certify that I will assess this patient (if he/she is a minor) at least three (3) months after initiation of
medical marijuana therapy, in consultation with a pediatric sub-specialist in child psychiatry, pediatric neu-
rology, or developmental pediatrics. This assessment and consultation will be documented in the patient's
medical record. ________ (Initial here)
I hereby certify that I will discontinue medical marijuana therapy if there is no improvement in the patient's
presenting symptom/s as listed above or is there is a worsening of those symptoms. If this is the case, I
agree to contact the RIDOH Medical Marijuana Program to withdraw this Certification. (NOTE: Another
trial of medical marijuana therapy will be allowed only after the passage of at least three (3) months after the
previous trial of medical marijuana has been discontinued.) ____________ (Initial here)
Practitioner’s Printed Name: _____________________________________________________________
Practitioner’s Signature ___________________________________________ DATE:________________
Medical Marijuana Program - Page 5
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