Department of Licensing and Regulatory Affairs
DLARA/MMP-500 (Rev. 4/11)
Michigan Medical Marihuana Registry
P.O. Box 30083
Lansing, MI 48909
Instructions for Applying for a Medical Marihuana Registry Identification Card
To be eligible for the Michigan Medical Marihuana Registry, you must complete the application packet and
submit the following information together in one envelope:
APPLICATION FORM FOR REGISTRY IDENTIFICATION CARD
REQUIRED: Complete Section A: APPLICANT/PATIENT INFORMATION
IF APPLICABLE: Complete Section B: PRIMARY CAREGIVER
o Required if you are designating a caregiver
"Primary caregiver" means a person who is at least 21 years old and who has
agreed to assist with a patient's medical use of marihuana and who has never
been convicted of a felony involving illegal drugs
REQUIRED: Complete Section C: PERSON ALLOWED TO POSSESS PATIENT’S MARIHUANA PLANTS
REQUIRED: Complete Section D: CERTIFYING PHYSICIAN INFORMATION
REQUIRED: Section E: ATTESTATION, SIGNATURE, & DATE
The Patient must sign and date the application
COPY OF PATIENT’S CURRENT PHOTO IDENTIFICATION
PHYSICIAN CERTIFICATION FROM MICHIGAN LICENSED MD/DO
Your physician must complete and sign the Physician Certification form. This must be submitted
with your application. DO NOT send or have medical records sent to the registry program.
Required if you designated a caregiver in Section B
COPY OF CAREGIVER’S CURRENT PHOTO IDENTIFICATION (IF APPLICABLE)
$100.00 APPLICATION FEE or $25.00 APPLICATION FEE if patient is currently enrolled in
Medicaid or receiving SSI or SSD, and submits the appropriate supporting documents
Check or money order only. Make payable to “State of Michigan—MMMP.” Do not send cash.
COPY OF DOCUMENTATION VERIFYING RECEIPT OF BENEFITS, IF SUBMITTING $25.00 FEE
Acceptable: Current Social Security Administration document stating the patient receives disability
benefits, MI Health card or other Medicaid health plan card (FULL Medicaid Only)
NOT ACCEPTABLE: Medicare card, Bridge card, Bank statements, Social Security IRS Form
1099, Social Security yearly benefits statement, VA disability, Retirement benefits
RETAIN A COPY OF YOUR APPLICATION FOR YOUR FILES
These are proof that your application is in process.
SEND ALL REQUIRED DOCUMENTS TOGETHER IN ONE ENVELOPE TO THE ADDRESS AT THE
OP OF THIS FORM:
Do not send any documentation separately from the application.
Your application will be approved or denied within 15 days of receipt by the department.
If determined incomplete, your application will be denied and you will receive a certified letter from the State
of Michigan. You can then resubmit a copy of your application with all required documents for reconsideration
without an additional fee (unless you were denied for an insufficient fee) for up to one year from receipt of
your denied application.
If approved, your application will be processed in the date order received. The patient, and if applicable, the
caregiver, will then be issued and sent a registry ID card to the mailing address provided on your application.
If the information provided on the application is determined to be false at any time, your registry ID card will
become null and void.
If you have questions, contact the Michigan Medical Marihuana Registry Program at (517) 373-0395.