Illinois Medical Cannabis Program Application For Registry Identification Card For Qualifying Patients Under 18 Years Of Age And Their Designated Caregivers

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State of Illinois
Illinois Department of Public Health
Illinois Medical Cannabis Pilot Program
Application for Registry Identification Card for
Qualifying Patients Under 18 Years of Age and their Designated Caregivers
INSTRUCTIONS
To qualify for a registry identification card for qualifying patients under 18 years of age, the qualifying patient
must:
be a resident of the state of Illinois at the time of application and remain a resident during participation in the
program;
have a qualifying debilitating medical condition;
have two signed physician certifications for the use of medical cannabis; and
submit a designated caregiver (custodial patient or legal guardian) application.
To qualify for a designated caregiver registry identification card for qualifying patients under 18 years of
age, the designated caregiver must:
be a resident of the state of Illinois at the time of application and remain a resident during participation in the
program;
complete the fingerprint-based background check and not have been convicted of an excluded offense (a
violent crime as defined in Section 3 of the Rights of Crime Victims and Witnesses Act or a felony under the
Illinois Controlled Substances Act, Cannabis Control Act or Methamphetamine Control and Community
Protection Act, or similar provisions in a local ordinance or other jurisdiction), unless they have an approved
waiver for the excluded offense;
serve as the custodial parent or legal guardian for the qualifying patient under 18 years of age; and
be at least 21 years of age.
A complete application must include all of the following:
A signed and completed application form.
Physician Written Certification form; the physician must mail in this form.
Physician Written Certification from a Reviewing Physician form; the reviewing physician must mail in this form.
Designated caregiver (custodial parent or legal guardian) information.
Proof of designated caregiver residency, identity, and age.
Designated caregiver copy of the fingerprint consent form and the receipt provided by the livescan fingerprint
vendor containing the Transaction Control Number (TCN).
Copy of the qualifying patient’s birth certificate.
Designated caregiver photograph (Contact the Department’s Division of Medical Cannabis if a photograph
would be in violation of or contradictory to the qualifying patient or designated caregiver’s religious convictions).
Selection of medical cannabis dispensary or zone.
A signed and completed Medical Cannabis Custodial Parent and Legal Guardian Attestation form.
If applicable, proof of guardianship documentation.
Application fee.
This application must be submitted to:
Illinois Department of Public Health
Division of Medical Cannabis
535 West Jefferson Street
Springfield, Illinois 62761-0001
Page 1 of 3
Printed by Authority of the State of Illinois
IOCI 15-164
P.O.#3115001
2M
12/14

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