Maine - Designation Form - State Of Maine Department Of Health And Human Services printable pdf download

Maine - Designation Form - State Of Maine Department Of Health And Human Services

STATE OF MAINE

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Maine Center for Disease Control and Prevention

Medical Use of Marijuana Program

Designation Form

SECTION 1: Qualifying Patient Information

Legal Name:

Date of Birth:

Telephone Number: (

)

Home Address:

City:

State:

Zip:

County:

Medical Provider Written Certification:

Issued Date: ___________________

Expiration Date: ___________________

SECTION 2: Cultivation Designation

_______ # of plants I will cultivate

_______# of plants my caregiver will cultivate

_______# of plants my dispensary will cultivate

Total # (Not to exceed 6) _________

Visiting qualifying patient (must be included as 1 of the 5 patients allowed per caregiver)

Non cultivating caregiver

A patient may designate either a primary caregiver or a dispensary to cultivate

For questions regarding this program, please contact 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:

dhhs.mmmp@maine.gov

Website:

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Form 110103 Rev 11/2016

Maine - Designation Form - State Of Maine Department Of Health And Human Services