Form Oha 9345 - Replacement Card Request
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1PUBLIC HEALTH DIVISION
Oregon Medical Marijuana Program
Replacement Card Request
Use this form to request replacement cards. All cards associated with the below patient’s
current registration will be replaced. Please type or print legibly.
Section1 — Patient — (required)
Legal name (last, first, mi):
Date of birth:
Mailing address:
Apartment number:
City:
State:
ZIP:
Section 2 — Reason for replacement request — (optional)
Lost
Stolen
Other:
Section 3 — Signature (required)
/
/
Patient signature
Date
The replacement card fee is $100.00 for lost or stolen cards.
The replacement card fee is reduced to $20 if the patient submits current proof of one of the following:
Supplemental Security Income (SSI)*
Having served in the U.S. armed forces
*Social Security Disability Income and retirement benefits do not qualify.
OMMP fees are non-refundable. Make checks payable to OHA/OMMP. Do not send cash.
Mail this form, check or money order and reduced fee proof (if applicable) to:
OHA/OMMP
PO Box 14450
Portland, OR 97293-0450
Oregon Medical Marijuana Program | 971-673-1234 |
1
OHA 9345 (12/2016)
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