Form Mmp 3502a - Caregiver Change Form
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2MMP 3502A (Rev. 1/15)
Michigan Medical Marihuana Program
Caregiver Change Form
(517)284-6400
For Current Registry ID Card Holders Only
Caregiver Change Form Instructions
1. Make checks or money orders payable to: State of Michigan-MMMP
2. Keep a copy of all documents submitted for your records.
3. Mail Change Form and all required documentation (see below) in one envelope to:
Michigan Medical Marihuana Program
PO Box 30083
Lansing, MI 48909
Caregiver Change Form Checklist
Name Change
Legal documentation*
Signed & dated Change Form
Copy of Caregiver’s valid MI photo ID
** $10 Fee
Address Change
Signed & dated Change Form
Copy of Caregiver’s valid MI photo ID **
$10 Fee per card
Removing a Patient
Signed & dated Change Form
Copy of Caregiver’s valid MI photo ID**
$10 Fee per patient removed
Request Replacement Caregiver Card(s)
Signed & dated Change Form
Copy of Caregiver’s valid MI photo ID**
$10 Fee per card
* Certified court document supporting name change: ie. marriage/divorce decree, legal name change document, valid MI driver's license or
Michigan ID, etc
** A copy of a valid MI driver’s license, MI identification card or MI voter registration. Cannot accept expired photo IDs.
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