Replacement Card Request
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1Oregon Medical Marijuana Program
PO Box 14450
Portland, OR 97293-0450
(971) 673-1234 (Mon – Fri, 9:00am - 4:00pm)
Replacement Card Request
Use this form to request replacement cards. All cards associated with the below patient’s
registration number will be replaced. Please type or print legibly.
PATIENT –
REQUIRED
LEGAL NAME (Last, First, MI):
DATE OF BIRTH:
MAILING ADDRESS:
PHONE:
The Replacement Card fee is $100.00 for lost or stolen cards.
The replacement card fee is reduced to $20 if the patient submits current proof of one of
the following:
a) Supplemental Security Income (SSI),*
b) Service connected compensation from the VA based on a finding by the VA of 100% service-
connected disability, OR
Receipt of a needs-based pension from the VA as described in OAR 333-008-0020.
c)
*Social Security Disability Income (SSDI) and Social Security Retirement benefits do not qualify.
REASON FOR REPLACEMENT REQUEST-- OPTIONAL:
Lost
Stolen
Other: _______________
PATIENT
SIGNATURE & DATE – REQUIRED
PATIENT SIGNATURE:
DATE:
OHA/OMMP
Mail completed request form with check
PO Box 14450
or money order to:
Portland, OR 97293-0450
Oregon Medical Marijuana Program • 971-673-1234 •
Rev. 10/14
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