Voluntary Caregiver Registration Form - Colorado Department Of Public Health And Environment

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VC
Voluntary Caregiver Registration
The Voluntary Caregiver Registry provides patients with contact information for primary caregivers in their area. By
STAFF
submitting this form, your name and contact information will appear on a list distributed to patients in search of a
ONLY
caregiver.
The Voluntary Caregiver Registry is only open to caregivers with fewer than 5 patients. Should you at any point provide
caregiver services for 5 or more patients, your name will not appear on the list. Should your patient count drop below 5,
__________
your name will reappear on the list. This list is updated weekly.
Evaluated
Submit this form with a copy of your Colorado driver’s license or photo ID.
Submit paperwork by mail or deliver to the Registry’s drop-box:
Mail: Application Processing, CDPHE, HSV-8608, 4300 Cherry Creek Dr S, Denver, CO 80246-1530
Deliver to drop-box: 710 S Ash St, southeast entrance, Monday-Friday, 7:00 a.m. to 6:00 p.m.
The drop box is on the wall inside the first set of glass doors. Your paperwork must be in a
sealed envelope. You will not receive a receipt. If you wish to have a receipt, please mail in
your paperwork by certified mail.
Processing time:
Please allow 2-5 weeks from the date the Registry receives your paperwork for standard
processing.
This is a request to be:
Added to the Voluntary Caregiver Registry
Removed from the Voluntary Caregiver Registry
Caregiver Information:
1. Last Name
2. First Name
3. Middle Initial
4. Date of Birth
5a. Mailing Address
5b. Apt/Ste #
6. City
7. State
8. Zip Code
9. County
CO
10. Telephone
11. Email
I hereby give the Registry permission to release my name and contact information to patients in search of a caregiver.
12a. Signature:
12b. Signature Date
4300 Cherry Creek Dr S, HSV-8630, Denver, CO 80246 | 303-692-2184
medical.marijuana@state.co.us
|
MMR1010 Voluntary Caregiver Registry | Revised March 2016

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