Written Certification Form (Page 4 of 4) in pdf

Written Certification Form Page 4

State of Illinois

Illinois Department of Public Health

Illinois Medical Cannabis Pilot Program

Reviewing Physician Written Certification Form

for Qualifying Patients Under 18 Years of Age

ATTESTATIONS

I _____________________________________________ (the reviewing physician), have confirmed a diagnosis

of a debilitating medical condition, as defined in the Compassionate Use of Medical Cannabis Pilot Program

Act, for the qualifying patient and have completed a comprehensive review of the qualifying patient’s medical

history, including the review of medical records from other treating physicians.

Initial: _______________

I _____________________________________________ (the reviewing physician), hereby certify I am a

physician duly licensed to practice medicine in the state of _______________. It is my professional opinion

that the qualifying patient is likely to receive therapeutic or palliative benefit from the use of medical cannabis

to treat or alleviate the patient’s debilitating medical condition or symptoms of the debilitating medical condition.

The qualifying patient has the debilitating medical condition(s) specified and it is my professional opinion the

potential benefits of the medical use of cannabis would likely outweigh the health risks for this patient.

_____________________________________________________________

____________________________

Physician signature (no stamps accepted)

Date of signature (mm/dd/yyyy)

Page 4 of 4

Printed by Authority of the State of Illinois

IOCI 15-164

P.O.#3115003

9/14

Written Certification Form Page 4