Application For Qualifying Patient Registry Identification Card Page 4
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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
REQUIRED DOCUMENTS
Place the following items in an envelope and attach to fingerprint consent form:
❑
Non-refundable application fee (Check or Money Order to Illinois Department of Public Health)
❑
Photograph
• Taken in the last 30 days
• Taken against a plain, white or off-white background or backdrop
• In natural color (Do not use a filter)
• Full-face view directly facing the camera with a neutral facial expression and both eyes open
• At least 2 inches by 2 inches in size
It is recommended you use a passport photo vendor to ensure the photograph meets these requirements.
Contact the Division of Medical Cannabis if a photograph is in violation of or contradictory to the qualifying patient’s religious
convictions.
Attach the following supporting documents to the fingerprint consent form:
❑
Proof of age and identity
Submit a clear, color copy of an Illinois Driver’s License, Illinois State ID, or the photograph page of a US passport.
❑
Proof of residency
If your Driver’s License or State ID address matches your application submit one additional proof of residency. If you submit a
US Passport as your proof of identity or your Driver’s License or State ID address does not match the address on your application,
submit two of the following:
• Pay stub or electronic deposit receipt issued less than 60 days prior to the date of application that shows evidence of the
applicant’s withholding for state income tax
• Valid Voter Registration card
• Deed/title, mortgage, rental/lease agreement
• Insurance policy (homeowner’s or renter’s)
• Medical claim or statement of benefits (from private insurance company or government agency), dated less than 90 days
prior to application; Social Security Disability Insurance Statement; or Supplemental Security Income Benefits States.
• Tuition invoice/official mail from college or university, dated 12 months prior to application
• Utility bill, including, but not limited to, those for electric, water, refuse, telephone land-line, cable or gas, issued less than
60 days prior to application
• Notarized homeless status certification:
https://
If you are using this form, you only need this document to prove residency
Proof of residency must include name and address and match the address on the application
❑
Fingerprint receipt
A listing of live scan fingerprint vendors can be found at https:// Contact the
live scan fingerprint vendor before having fingerprints taken to make sure they take Medical Cannabis fingerprints. Remember
to bring the fingerprint consent form to the vendor and add the Transaction Control Number (TCN) to your form. Once you have
your fingerprints taken, the fingerprint consent form and the receipt provided by the live scan fingerprint vendor containing the
TCN must be sent in with your application. Fingerprints must be taken within 30 days of submitting your application.
❑
Benefit Verification Letter from the Social Security Administration or DD-214 (if applicable)
Mail the application and required documents to:
DO YOU NEED A CAREGIVER TO ASSIST WITH
Illinois Department of Public Health
THE USE OF MEDICAL CANNABIS?
Division of Medical Cannabis
To designate a caregiver now, complete the
535 West Jefferson Street
Designated Caregiver Application and submit the
Springfield, Illinois 62761-0001
required documents with your patient application.
Questions? Contact the Division of Medical Cannabis at 855-636-3688 or DPH.MedicalCannabis@Illinois.gov.
Page 4 of 4
Printed by Authority of the State of Illinois
IOCI 16-532
P.O.#3116010
10M
3/16
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