Change/re-Issue Form - State Of Maine Department Of Health And Human Services
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1
2STATE OF MAINE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Medical Use of Marijuana Program
Change/Re-issue Form
Caregiver
Employee
SECTION 1: Caregiver/Employee Information
Legal Name:
Date of Birth:
Telephone Number: (
)
Mailing Address:
City:
State:
Zip:
County:
SECTION 2: Replacement card information
Please indicate why you are requesting a replacement card:
($8 Re-issue Fee-Per Card)
Card was lost or stolen
Card was damaged
Submit completed application and applicable fees to the following:
Department of Health and Human Services
Maine Center for Disease Control and Prevention
Maine Medical Use of Marijuana Program
286 Water Street
11 State House Station
Augusta, ME 04333-0011
Tel: (207) 287-8016
Fax: (207) 287-2671
TTY users: Dial 711 (Maine relay)
Email: MMMP, DHHS
DHHS.MMMP@maine.gov
Website:
Office Use Only:
Check/MO # ____________________________
Amount $________________
Initials: ____________
Page 1 of 2
Form 110102 Rev 11/2016
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