Illinois Medical Cannabis Program Application For Registry Identification Card For Qualifying Patients Under 18 Years Of Age And Their Designated Caregivers (Page 2 of 7) in pdf

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

Qualifying patients under 18 years of age must submit two (2) physician certifications.

The qualifying patient’s physician shall certify the existence of a bona-fide physician-patient relationship; conduct an

in-person physical examination of the qualifying patient within 90 days of the application; complete an assessment

of the qualifying patient’s medical history; confirm the qualifying patient has a qualifying debilitating medical condition;

explain the potential risks and benefits of medical cannabis use to the qualifying patient and designated caregiver;

and certify the qualifying patient is likely to receive a therapeutic or palliative benefit from the use of medical

cannabis-infused products.

The reviewing physician shall review the qualifying patient’s medical history; confirm the qualifying patient has a

qualifying debilitating condition; and certify the qualifying patient is likely to receive a therapeutic or palliative benefit

from the use of medical cannabis-infused products.

Physician Written Certification

Make sure the qualifying patient’s physician completes the

Physician Written Certification Form

and mails it to the

Department’s Division of Medical Cannabis.

Physician Written Certification from a Reviewing Physician

Make sure the qualifying patient’s reviewing physician completes the

Physician Written Certification from a Reviewing

Physician Form

and mails it to the Department’s Division of Medical Cannabis.

Proof of designated caregiver residency, identity and age

Attach a copy of any of the following items:

•

Notarized homeless status certification:

•

A valid, unexpired Illinois driver’s license or other state identification card issued by the Illinois secretary of state.

Designated Caregiver Uniform Conviction Information Act (UCIA) Fingerprint Consent Form and the receipt

provided by the livescan fingerprint vendor containing the Transaction Control Number (TCN)

Uniform Conviction Information Act (UCIA) Fingerprint Consent

Submit a copy of the UCIA Fingerprint Consent Form. You may obtain a current listing of

livescan fingerprint vendors from the Illinois Department of Financial and Professional Regulation website at

https:// Contact the live scan fingerprint vendor before going to get

your fingerprints taken. When you go to get your fingerprints taken, remember to bring the UCIA Fingerprint Consent

Form. Once you have your fingerprints taken, the UCIA Fingerprint Consent Form and receipt provided by the livescan

fingerprint vendor containing the Transaction Control Number (TCN) must be returned to the Department’s Division

of Medical Cannabis along with the completed application.

Medical Cannabis Custodial Parent and Legal Guardian Attestation Form

This form can be downloaded from the Illinois Department of Public Health’s Medical Cannabis website

Page 2 of 3

Printed by Authority of the State of Illinois

IOCI 15-164

P.O.#3115001

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Illinois Medical Cannabis Program Application For Registry Identification Card For Qualifying Patients Under 18 Years Of Age And Their Designated Caregivers Page 2

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