Medical Cannabis Program

Transcription

1 Medical Cannabis Prgram Website: Telephne Number: Checklist fr Patient Applicatins This checklist is fr new applicants and current patients ( renewing patients). Yu can use it t be sure yu have all the dcuments yu need fr yur applicatin. There is n charge fr the patient ID card (there is a $50 charge fr a replacement card). An applicatin that isn t cmplete r hard t read may delay yur card. Yu will be ntified, and yur applicatin will be held fr up t 6 mnths. If it s still nt cmplete, a new applicatin will be needed. Submit ORIGINAL pages t the Medical Cannabis Prgram. The prgram cannt accept phtcpies, faxes r electrnic cpies. Please keep a cpy f everything yu send in, including yur New Mexic ID. Renewal applicatins can be submitted in up t 90 days prir t yur cards expiratin date. Cmpleted Patient Infrmatin Frm (Page 1). Use the attached instructins t help yu make sure yur frm is cmplete. Cmpleted Medical Certificatin Frm (Page 2). This is filled ut by yur medical prvider. Cpy f clinic ntes. Ask yur medical prvider fr these. Clear cpy f a valid New Mexic pht ID r Driver s License. Temprary r Extensin IDs will be accepted with BOTH the paper cpy and hle punched r ld ID. Fr thse under the age f 18, a clear cpy f the birth certificate and a cmpleted Caregiver Applicatin and the dcuments needed fr that applicatin. Fr thse 18 years ld r lder wh need a caregiver, a cmpleted Caregiver Applicatin and the dcuments needed fr that applicatin. Once cmplete, please mail r drp ff yur applicatin t the Medical Cannabis Prgram: Mailing Address: Department f Health Physical Address: Department f Health Medical Cannabis Prgram Medical Cannabis Prgram 1190 S St Francis Dr Rde Drive PO Bx Suite 200 Santa Fe, NM Santa Fe, NM If yu want t grw yur wn medical cannabis, cmplete and send in the applicatin fr a Persnal Prductin License (PPL). This is fr patients nly and must be cmpleted annually and when any infrmatin changes.

2 Medical Cannabis Prgram Website: Telephne Number: Instructins fr Patient Applicatins This applicatin is fr new applicants and current patients ( renewing patients). There is n charge fr patient cards (there may be a charge if a card is lst). PLEASE PRINT CLEARLY r TYPE YOUR APPLICATION The frm can be cmpleted using a cmputer and then printed. If yu d nt have a cmputer/printer, handwritten frms are fine. Page 1 Filled ut by yu (the patient) r yur caregiver (if yu have/need ne refer t the Caregiver Applicatin r call fr mre infrmatin abut this). Check ne f the bxes t tell us if yu are a new applicant r renewing (current) patient. Write r type in: Yur first, middle, and last name and any suffix like Sr. r Jr. (matching yur state ID); Yur gender, date f birth (MM/DD/YYY), and the language yu speak mst ften; The address where yu want yur mail sent (mailing address); The address where yu stay mst nights (physical address); and Yur phne number and address (if yu have ne). The questins in the bx are ptinal but yur answers help us better serve peple in the prgram. Fill ut the items yu feel cmfrtable answering. Leave the rest blank. Sign and date the frm. This must be an ORIGINAL signature nt a phtcpy. If the patient is 18 years ld r lder and the frm is signed by smene else, please send prper legal papers that shws this signature is allwed by law. The persn signing the frm must als cmplete a Caregiver Applicatin. If the patient is under 18 years ld and the frm is signed by smene else, please include a cpy f the patient s birth certificate. The persn signing the frm must als cmplete a Caregiver Applicatin. Make a clear cpy f yur NM State ID (driver s license r state issued ID card) t include with yur applicatin. If yu have a temprary ID, make a cpy f the paper/temprary ID and the ld ID that had a hle punched in it by the Mtr Vehicles Divisin (MVD). Send bth phtcpies with the applicatin. Page 2 Filled ut by yur medical prvider (e.g., dctr, nurse, psychlgist, dentist, etc. wh is allwed by law t prescribe medicine in the state f New Mexic). Be sure yur prvider fills in everything and signs the frm. These must be ORIGINAL signatures. The applicatin must be received by the Medical Cannabis Prgram within 90 days frm the date that the prvider signs the frm.

3 Medical Cannabis Prgram Website: Telephne Number: Patient Infrmatin Frm TO BE COMPLETED BY THE PATIENT New Patient Renewing Patient (Already in prgram even if card has expired) First Name: Last Name: Middle Name: Suffix (e.g. Sr., Jr.): Hw wuld yu describe yurself? Man Wman Transgender Transgender Man Transgender Wman Other: Date f Birth (MM/DD/YYYY): Mailing Address: Cunty: Physical Address: Cunty: Phne Number: Language yu speak mst ften: City: Zip: City: Zip: Questins in this bx are ptinal. Yur answers help us better serve peple in the prgram. If yu dn t want t answer smething, leave it blank. Please check the race r ethnicity yu call yurself. Check all that apply. American Indian r Alaska Native Latin r Hispanic American Tribe: Native Hawaiian r Pacific Islander Asian White Black r African American Other: Are yu a Veteran? Yes N Applicant Signature: By signing belw, I agree that: All the infrmatin given abve is cmplete and crrect. I will fllw the limits and restrictins n my right t have and use medical cannabis that are in the laws f New Mexic (the Lynn and Erin Cmpassinate Use Act and the New Mexic Administrative Cde ). These laws are n the prgram s website at: nmhealth.rg/g/mcp. I allw the New Mexic Department f Health, Medical Cannabis Prgram t discuss my medical cnditin, including treatment recrds, test results and evaluatins specific t enrllment in the Medical Cannabis Prgram with the medical prvider(s) named in this applicatin. Applicant Signature * (Please print frm then sign) Date * If signed by smene ther than the applicant, send prper legal dcuments (see instructins fr mre infrmatin) Mail t: DOH - Medical Cannabis Prgram; 1190 S. St. Francis Dr.; PO Bx 26110; Santa Fe, NM; NMDOH USE ONLY Date Card Printed: Reviewed By: Caregiver App Attached: YES NO PPL App Attached: YES NO Check Number: Disclsure Frm n File: YES NO Unit Increase Letter Attached: YES NO Page 1 f 2 Please send all pages at the same time

4 Medical Cannabis Prgram Website: Telephne Number: Applicant Full Name: Lcatin f Exam: Medical Certificatin Frm TO BE COMPLETED BY A MEDICAL PROVIDER Date f Birth (MM/DD/YYYY): Patient in yur care fr hw lng: Medical Reasn fr Prvider Certificatin - Please check all that apply and circle the primary certifying cnditin Amytrphic Lateral Sclersis (ALS) Cancer (please specify type in clinical ntes) Intractable Nausea/Vmiting Multiple Sclersis Crhn s Disease Damage t the nervus tissue f the spinal crd Epilepsy/Seizure Disrders (please prvide prf f bjective neurlgical indicatin f intractable spasticity in clinical ntes) Glaucma Painful Peripheral Neurpathy HCV infectin and currently receiving antiviral treatment (please prvide prf f antiviral Parkinsn s disease treatment in clinical ntes) Pst Traumatic Stress Disrder HIV/AIDS Severe Chrnic Pain Huntingtn s Disease Severe Anrexia/Cachexia Hspice Care Spasmdic Trticllis (Cervical Dystnia) Inclusin Bdy Mysitis Ulcerative Clitis Inflammatry autimmune-mediated arthritis PLEASE ATTACH mst recent clinic ntes cnfirming the applicant s diagnsis Prvider Name: Clinical Licensure (MD, DO, NP, PA, etc.): Bard Certified Specialty: NM Medical License #: DEA License #: NM Cntrlled Substance License #: Office Address: City: State: NM Zip: Mailing Address: City: State: NM Zip: Prvider Telephne Number: Secnd Telephne Number: By signing belw, yu are certifying that, based n yur in persn examinatin f the patient: The patient s cnditin is chrnic and debilitating; Yu have discussed the ptential risks and benefits with the patient, and find that ptential health benefits f the medical use f cannabis likely utweigh the health risks fr the patient; Yu understand the Medical Cannabis Prgram needs clinical recrds fr verificatin purpses; and Yu are licensed in New Mexic t prescribe and administer drugs that are subject t the Cntrlled Substances Act and yur primary practice is in New Mexic. Medical Prvider Signature: (Please print frm then sign) Date: (Must be dated within 90 days f receipt by prgram) NMDOH USE ONLY Prgram Staff Signature: Date: Apprved Denied Request fr Recrds Sent Additinal ntes in BiTrack Page 2 f 2 Please send all pages at the same time

5 Medical Cannabis Prgram Website: Telephne Number: Instructins fr Prviders Practitiners must have a physician-client relatinship with the qualified patient, and cnduct inpersn evaluatins f the qualified patient prir t issuing a certificatin. PLEASE PRINT CLEARLY r TYPE THE APPLICATION The frm can be cmpleted using a cmputer then printed and signed, r it can be handwritten. Page 1 - Cmpleted by the patient including their name, demgraphics, current address, current telephne number, and riginal signature (phtcpies nt accepted). Page 2 - Filled ut by a medical prvider (e.g., dctr, nurse, psychlgist, dentist, etc. wh is allwed by law t prescribe cntrlled substances in the state f New Mexic). Please Nte: Resident Physicians and Fellws d n have the credentials necessary t meet regulatry requirements. Please have attending physicians cmplete the certificatin. Ensure the fllwing infrmatin is present: Patient s legal name and date f birth (matching the patient s state ID); The address where the exam tk place and hw lng this patient has been in yur care; Reasn fr prvider s certificatin (i.e., apprved cnditin/diagnsis); Check all cnditins that apply t the patient and circle the primary certifying cnditin. Prvider s infrmatin; Name, clinical license held, and bard specialty; NM Medical License number; NM Cntrlled Substance License number; Federal DEA License number; Office address, mailing address, and phne numbers. Original prvider signature and date (phtcpies nt accepted). Medical ntes must be attached t the frm t prvide additinal supprt fr the patient s applicatin. Ensure these materials are submitted with the applicatin. All riginal pages f the applicatin, a phtcpy f the patient s current New Mexic State ID (i.e., driver s license r state issued ID card) and supprting dcuments shuld be submitted tgether. This may be dne by the patient r the practitiner. A practitiner shall nt be subject t arrest r prsecutin, penalized in any manner r denied any right r privilege fr recmmending the medical use f cannabis r prviding written certificatin fr the medical use f cannabis as per NM statue.