Application For Qualifying Patient Registry Identification Card Page 2
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State of Illinois
Illinois Department of Public Health
Illinois Medical Cannabis Pilot Program
Application for Registry Identification Card for Qualifying Patients
CERTIFICATIONS
I certify the information provided in this application is true and accurate to the best of my knowledge.
Submission of false, misleading or inaccurate information in connection with this application is grounds for revocation of my
Illinois Medical Cannabis Qualifying Patient Registry Identification Card and other administrative, civil or criminal penalties.
I additionally certify that I have been given actual Notice and understand that, notwithstanding the Compassionate Use of Medical Cannabis
Pilot Program Act (Act):
(i) cannabis is a prohibited Schedule I controlled substance under federal law;
(ii) participation in the program is permitted only to the extent provided by the strict requirements of the Act;
(iii) any activity not sanctioned by the Act may be a violation of state or federal law and could result in arrest, conviction, or
incarceration;
(iv) growing, distributing, or possessing cannabis under the Act, unless done through a federally-approved research program, is a
violation of federal law;
(v) growing, distributing, or possessing cannabis in any capacity, except through a federally-approved research program, may
be a violation of state or federal law and could result in arrest, conviction or incarceration;
(vi) use of medical cannabis, or possessing a medical cannabis patient or caregiver registry card, may affect an individual’s
ability to receive or retain federal or state licensure in other areas;
(vii) use of medical cannabis or possessing a medical cannabis patient or caregiver registry card, in tandem with other conduct,
may be a violation of state or federal law and could result in arrest, conviction or incarceration;
(viii) participation in the Medical Cannabis Pilot Program does not authorize any person to violate federal law or state law;
(ix) the Act does not provide any immunity from or affirmative defense to arrest or prosecution under federal law or state law, other
than as set out in 410 ILCS 130/25; and
(x) applicants shall indemnify, hold harmless, and defend the state of Illinois for any and all civil or criminal penalties resulting
from participation in the program.
_____________________________________________________________
____________________________
SIGNATURE OF QUALIFYING PATIENT
DATE (mm/dd/yyyy)
APPLICATION FEES
Provide a check or money order payable to Illinois Department of Public Health:
Annual qualifying patient application fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100
Annual reduced qualifying patient application fee* . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50
Annual designated caregiver application fee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $25
*The reduced fee is for qualifying patients enrolled in the Federal Social Security Disability Income (SSDI), Supplemental
Security Income (SSI) disability programs, or Veterans.
Patients enrolled in SSDI or SSI – Submit a “Benefit Verification Letter” from the Social Security Administration that shows your
name and address and the type of benefits that are received. This letter must be dated within the last year. You can get this letter
by using your My Social Security account online at https:// or calling the Social Security Administration
at 1-800-772-1213. Annual cost of living increase letters will not be accepted as proof because they do not show the type of
benefits received.
Veterans – Submit a copy of your DD-214 showing dates of service and character of service (type of discharge).
APPLICATION FEES ARE NOT REFUNDABLE
Page 2 of 4
Printed by Authority of the State of Illinois
IOCI 16-532
P.O.#3116010
10M
3/16
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Parent category: Medical