Maine - Designation Form - State Of Maine Department Of Health And Human Services (Page 3 of 3) in pdf

SECTION 5: Patient Rights and Responsibilities

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

Marijuana Program until ___________________. I have provided you with a copy of my Maine Medical Use of

Marijuana Program identification card/MMMP certification and my original designation 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 medical use of marijuana certification

issued by my 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 my

Maine provider certification and a copy of my photographic identification card or driver’s license from my home

jurisdiction. As a visiting qualifying patient, I agree to abide by all terms and conditions of the Maine Medical Use of

Marijuana Program.

You are hereby authorized to share this caregiver designation form and any copies of documents that I am required to

provide to 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. This MMMP designation form and designation card is my

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

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

patient. You will have 10 days from the date of notice to return this form to me.

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 and card 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 designee

Signature of designee

Date

Numeric identification assigned by the designee: _____________________

Page 3 of 3

Form 110103 Rev 11/2016

Maine - Designation Form - State Of Maine Department Of Health And Human Services Page 3