Medical Use Of Marijuana Program Patient Application
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1
2STATE OF MAINE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF LICENSING AND REGULATORY SERVICES
Medical Use of Marijuana Program
Patient Application
SECTION 1: Patient Information
New Application
Renewal Application
Legal Name:
Date of Birth:
Driver’s License No.:
Telephone No.: (
)
Home Address:
City:
State:
Zip:
Mailing Address:
City:
State:
Zip:
Grow Location Address (if growing own marijuana):
City:
State:
Zip:
Email Address:
SECTION 2: Fees
APPLICATION FOR PATIENT
An application for a Registry Identification Card is voluntary for qualifying patients. There is no fee to register.
Possession of a Registry Identification Card will assist law enforcement officials in verifying that you may possess and/or
cultivate marijuana for your medical use.
•
If a patient chooses not to register, non-registered patients must be able to present to law enforcement upon
request: (1) the original physician certification form, and (2) a Maine driver’s license or other Maine-issued
photo identification card.
•
A Maine driver’s license or other Maine-issued photo identification card is required to be provided for both
registered and non-registered patients.
For questions regarding this program and/or application, please contact the following:
Department of Health and Human Services
Licensing and Regulatory Services
Maine Medical Use of Marijuana Program
41 Anthony Ave
11 State House Station
Augusta, ME 04333-0011
Tel: (207) 287-4325
Fax: (207) 287-2671
Toll Free: 1-800-791-4080
TTY users call Maine relay 711
Email:
medmarijuana.dhhs@maine.gov
Office Use Only:
Check# ___________
MO # ________________________ Amount $___________ Initials: ________ License# ______________
Page 1 of 2
Form 110102 Rev 5/2013
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Parent category: Medical