Oregon Medical Marijuana Program Application Form

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Oregon Medical Marijuana Program
APPLICATION FORM INSTRUCTION and FEES
OMMP FEES ARE NON-REFUNDABLE
APPLICATION FEES
$200.00
No reduced fee proof is submitted and the Patient and Grower on the application are the same person.
$250.00
No reduced fee proof is submitted and the Patient and Grower on the application are different people.
1
$60.00
Current proof of SNAP/Oregon Food Stamps
receipt is submitted and the Patient and Grower on the
application are the same person.
1
$110.00
Current proof of SNAP/Oregon Food Stamps
receipt is submitted and the Patient and Grower on the
application are not the same person.
2
$50.00
Current proof of Oregon Health Plan
receipt eligibility is submitted and the Patient and Grower on the
application are the same person.
2
$100.00
Current proof of Oregon Health Plan
receipt eligibility is submitted and the Patient and Grower on the
application are not the same person.
3
$20.00
Current proof of Supplemental Security Income
receipt eligibility is submitted and the Patient and
Grower on the application are the same person.
3
$70.00
Current proof of Supplemental Security Income
receipt eligibility is submitted and the Patient and
Grower on the application are not the same person.
1
SNAP/Food Stamps: To qualify for the reduced fee, a copy of current proof of both the patient’s SNAP food stamp benefits and
Oregon residency (Oregon driver’s license or ID) must be provided at the time the patient submits an application.
2
OHP: To qualify for a reduced fee, a copy of current proof of both the patient’s Oregon Health Plan eligibility and Oregon
residency (Oregon driver’s license or ID) must be provided at the time the patient submits an application.
3
SSI: To qualify for a reduced fee, a copy of Supplemental Security Income monthly benefit receipt or eligibility for the current
Social Security Disability Income (SSDI) and
year must be provided at the time the patient submits an application.
do not qualify
Social Security Retirement benefits
for a reduced application fee.
MINORS
If the applicant is a minor (under age 18), the custodial parent or legal guardian with responsibility for health care
decisions must submit a notarized declaration and be listed as the Caregiver on the application. If the minor’s
Caregiver is also the minor’s Grower, the growsite registration fee is waived.
CRIMINAL HISTORY CHECK
According to ORS 475.304(6)(a), the Authority shall conduct a criminal records check under ORS 181.534 of any
person whose name is submitted as a Grower.
OHA/OMMP
Complete the application on the reverse side,
PO Box 14450
include the Attending Physician’s Statement,
Portland, OR 97293-0450
ID copies, check or money order, and mail to:
Until this application has been approved or denied by
The Oregon Medical Marijuana Act neither protects
the Oregon Medical Marijuana Program, a copy of
marijuana plants from seizure nor individuals from
these materials (along with proof of mailing or
prosecution if the federal government chooses to take
transmission) shall have the same legal effect as a
action against patients or caregivers under the federal
registration card. ORS 475.309(9)
Controlled Substances Act.
If you have any questions, need this document in an alternative format, or you would like a copy of the
rules or statutes, please contact the OMMP at 971-673-1234 (Monday – Friday, 11:00 am to 4:45 pm).
Do Not Fax
Rev 10/13

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