Montana Marijuana Program Change Request Form
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1
2Montana Marijuana Program
CHANGE REQUEST FORM
Registered cardholders (patients) and providers/MIPPS must use this form to submit any
information changes to the department.
REVIEW THE CHECKLIST BELOW BEFORE SUBMITTING THIS FORM TO THE DEPARTMENT
Mail this completed form to DPHHS/MMP, PO Box 202953, Helena, MT 59620‐2953
There is no fee for submitting a change request
More than one change can be made on a single form
If a patient is adding or changing provider/MIPP, the patient and new provider/MIPP must sign form.
Provider information will only be changed if the provider submits a change request form. Provider
information will not be changed if the change request form is for a registered cardholder.
Add Provider
Change Provider
Remove Provider
Remove Patient
Name Change (requires legal documentation)
Street address Change
Mailing address change
Registered premises (grow location) address change*
Other, Specify
*If you will be cultivating and/or manufacturing marijuana at an address that is rented or leased, you must
include a LANDLORD PERMISSION FORM with this change request.
REGISTERED CARDHOLDER (PATIENT) INFORMATION
COMPLETE THIS SECTION IF THE REGISTERED CARDHOLDER IS CHANGING PERSONAL INFORMATION OR
ADDING OR REMOVING A PROVIDER
Current card number: ________________Expiration date: _______________
Legal Name (Last):
(First):
MI:
Social Security Number: _________________________ Phone Number:________________________________
Montana Driver’s License number or State of Montana issued ID number:
_
Mailing Address: _______________________________ City: ____________________ Zip Code: ____________
Street Address:
___ City: ____________________ Zip Code: ____________
Registered Premises Address: _________________________________________________________________
City: _______________
Zip Code: _____________
Signature of registered cardholder
Date
CRF
Page 1 of 2
1/17/2012
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