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SECTION 7: Patient Rights and Responsibilities

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My physician has certified that I have a condition that entitles me to participate in the Maine Medical Use of

Marijuana Program until ___________________, when my physician certification expires. I have provided you with

either a copy of that certification or a copy of my Maine Medical Use of Marijuana Program identification card as

proof that I am authorized to participate in the program. I have also provided you a copy of my Maine issued driver

license or other Maine issued photo identification card as proof of my identity.

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If I am visiting from another state, I have provided you with a copy of the MMMP physician certification form

completed by my physician in the state of ________________ as evidence that I live in a state that authorizes

marijuana for medical purposes and have a debilitating condition authorized under Maine law. I have also provided

you with a copy of the driver license or other state issued photo identification card issued by that state as proof of

my identify.

In the event needed, you are hereby authorized to share this caregiver designation form and any copies of documents

that I am required to provide to you with a member of the law enforcement community in order to verify the services

you are providing to me are authorized under Maine law.

I have the right to terminate this agreement at any time upon written notice to you. This caregiver designation form is

my property, and any authorized activity conveyed to you through this designation form terminates upon my notice to

you. You must either dispose of the excess marijuana in your possession on my behalf, or replace me with another

qualified patient. By rue of the Department of Health and Human Services, you will have 10 days from the date of notice

to return this form to me at the address above.

In the event I terminate this agreement and you do not return this designation form to me, I authorize the Maine

Department of Health and Human Services to demand the return of this designation form or take other action to

enforce the Rules Governing the Maine Medical Use of Marijuana Program, which includes terminating the caregiver

number that they assigned to you and that you have listed on this designation form.

_______________________________________ _____________________________________ ____________________

Print name of patient/guardian

Signature of patient/guardian

Date

_______________________________________ _____________________________________ ____________________

Print name of caregiver

Signature of caregiver

Date

_______________________________________ _____________________________________ ____________________

Print name of dispensary representative

Signature of dispensary representative

Date

Page 3 of 3

Form 110103 Rev 12/2012

Medical Use Of Marijuana Program - State Of Maine Department Of Health And Human Services Page 3