Form Mmp-3051 - Add Or Change Caregiver Form

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For Official Use Only

$35 Fee Received

Michigan Medical Marihuana Program

(517)284-6400

Add or Change Caregiver Form

This form is for active registered PATIENTS who are adding or changing their caregiver. You may also change your address at this time. If

a new address is listed, we'll update your address on all active registry cards. Only one address is allowed per person in the program.

INSTRUCTIONS

Complete Sections A, B, and C and include the following:

o Patient: Include a copy of patient’s valid Michigan driver license, personal identification card, or signed

voter registration. If a patient submits a voter registration, he or she must include additional proof of

identity for verification purposes (i.e., government-issued document that includes your name and date

of birth).

o Caregiver: Include copy of new caregiver’s valid state-issued driver license or personal identification

card.

Sign and date the form.

Include check or money order for $35 made payable to: State of Michigan-MMMP.

Make a copy of the completed form and all required documentation for your records.

Do not include any other forms, fees, or documentation in the envelope.

Mail completed form and all required documentation in one envelope to:

Michigan Medical Marihuana Program

P.O. Box 30083

Lansing, MI 48909

Section A: Patient Information (As it appears on your current registry ID card) (REQUIRED)

Patient Registry ID Card Number (If known)

Date of Birth

Telephone Number

Legal First Name

Middle Initial

Legal Last Name

Suffix (Jr., Sr., etc.)

Mailing Address

Apartment/Suite/Lot #

(If your address has changed, provide your new address)

State

City

Zip Code

Section B: New Caregiver Information (REQUIRED)

Middle Initial

Legal First Name

Legal Last Name

Suffix (Jr., Sr., etc.)

Date of Birth

Aliases/Maiden Name

Gender (used for conviction history)

Female

Male

Mailing Address

Apartment/Suite/Lot #

City

State

Zip Code

Section C: Plant Possession (REQUIRED)

I will possess the plants

My caregiver will possess the plants

Plant possession: You must select one box. Select Only One:

Patient Signature & Declaration (REQUIRED)

I attest the information I provided is true and accurate and that I will comply with the requirements of the Michigan Medical Marihuana Act (Initiated

Law 1 of 2008, MCL 333.26421 et seq.) and associated administrative rules. I understand that falsified or fraudulent information may be reported to law

enforcement and result in criminal prosecution.

Signature of Patient:

Date:

____________________________

Caregiver Signature & Declaration (REQUIRED)

I attest the information I provided is true and accurate and that I will comply with the requirements of the Michigan Medical Marihuana Act (Initiated

Law 1 of 2008, MCL 333.26421 et seq.) and associated administrative rules. Further, I agree to serve as the patient’s primary caregiver, have no

convictions that will disqualify me from serving as a primary caregiver, and authorize the department to use the information provided to perform a

criminal background check. I understand that falsified or fraudulent information may be reported to law enforcement and result in criminal

prosecution.

Date:

Signature of Caregiver:

____________________________

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MMP-3051 (Rev. 9/17)