Application Form For Registration Of Minor Patient Form - Michigan Department Of Community Health
ADVERTISEMENT
1
2
3
4
5Michigan Department of Community Health
DCH/MMP-501 (3/09)
Michigan Medical Marihuana Program
P.O. Box 30083
Lansing, MI 48909
Instructions for Applying for a Medical Marihuana
Registry Identification Card for Minor Patient
To be eligible for the Michigan Medical Marihuana Registry, you must complete the application packet and
submit the following information:
APPLICATION FOR IDENTIFICATION CARD
•
Please complete the entire application form.
•
Complete the physician information.
•
Sign and date the application.
PHYSICIAN CERTIFICATION – TWO (2) COMPLETED CERTIFICATIONS FROM MICHIGAN
LICENSED MDs/DOs
•
Two physicians must complete and sign the physician certification forms.
DOCUMENTATION OF LEGAL GUARDIANSHIP
DECLARATION OF PERSON RESPONSIBLE FOR A MINOR APPLYING TO PARTICIPATE IN THE
MICHIGAN MEDICAL MARIHUANA REGISTRY
PHOTO ID
$100.00 APPLICATION FEE (Check or money order payable to State of Michigan—MMMP. $25.00
if enrolled in Medicaid Health Plan or receiving SSI.)
DOCUMENTATION VERIFYING RECEIPT OF BENEFITS FROM STATE OR FEDERAL AGENCIES
(IF APPLICABLE)
SEND ALL OF THE ITEMS TO:
Michigan Department of Community Health
Medical Marihuana Registry
P.O. Box 30083
Lansing, MI 48909
The information you provide will be verified within 15 days of receiving the application. If approved, your
card will be issued and sent to the address provided.
Your application will be denied if determined incomplete. You can resubmit your application with all of the
necessary information for reconsideration without an additional fee for up to one year from the date your
first application was received.
If the information you provide on the application is determined to be false at any time, your registration card
will become null and void.
The applicant will receive one card with the patient’s information.
A separate card with the patient
caregiver information will be sent to the parent/legal guardian.
Keep copies of all the documents you send to the Michigan Marihuana Registry. These are proof that your
application is in process.
If you have questions, contact the Michigan Medical Marihuana Registry at (517) 373-0395.
Forms are available at
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Dch-0479 - Kindergarten Entry/preschool Hearing/vision Screening Record - Michigan Department Of Community Health
Legal
Form Bcs/cd-602 - Application For Registration Of Insignia - Michigan Department Of Licensing And Regulatory Affairs Bureau Of Commercial Services
Financial
Form Bcs/cd-600 - Application For Registration Of Trademark/service Mark - Michigan Department Of Licensing
Legal
Form I - Application For Registration Of Birth Of A Minor Child At An Indian Consulate Under Section 4 (1) Of The Citizenship Act, 1995
Business
Related Categories
Parent category: Medical