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Department of Licensing and Regulatory Affairs

DLARA/MMP-020 (4/11)

Michigan Medical Marihuana Registry

P.O. Box 30083

Lansing, MI 48909

Physician Certification

INSTRUCTIONS: THIS CERTIFICATION IS TO BE COMPLETED IN ITS ENTIRETY BY THE PHYSICIAN.

Please

complete all of the information required on this form. Sign the form and keep a copy in the patient’s medical record.

The patient must submit this certification along with his/her application for a Michigan Medical Marihuana

Registry identification card.

This does not constitute a prescription for marihuana. You may contact the Michigan

Medical Marihuana Program at (517) 373-0395 if you have any questions or concerns.

PLEASE TYPE OR PRINT LEGIBLY

PHYSICIAN INFORMATION: (REQUIRED)

SELECT ONE:  M.D.

Name (First, M.I., Last)

 D.O.

MAILING ADDRESS

REQUIRED: MICHIGAN

PHYSICIAN LICENSE NUMBER

CITY

STATE

ZIP CODE

TELEPHONE NUMBER

(

)

PHYSICIAN’S STATEMENT: (REQUIRED)

I certify that ___________________________________________________ ___________________ has been diagnosed with

Patient’s Name (REQUIRED)

Date of Birth

the following debilitating medical condition (check appropriate boxes):

OR a medical condition or treatment that produces, for this

 Cancer

patient, one or more of the following and which, in the

 Glaucoma

physician’s professional opinion, may be alleviated by the

 HIV or AIDS Positive

medical use of medical marihuana.

 Cachexia or Wasting Syndrome

 Hepatitis C

 Severe and Chronic Pain

 Amyotrophic Lateral Sclerosis

 Severe Nausea

 Crohn’s Disease

 Seizures (Including but not limited to those

 Agitation of Alzheimer’s Disease

characteristic of Epilepsy.)

 Nail Patella

 Severe and Persistent Muscle Spasms (Including

but not limited to those characteristic of Multiple

Sclerosis.)

Physician’s Comments: (Please Type or Print Legibly)

CERTIFICATION, SIGNATURE, & DATE: (REQUIRED)

I hereby certify that I am a physician licensed to practice medicine in Michigan. It is my professional opinion

that the applicant has been diagnosed with a debilitating medical condition as indicated above. The medical

use of marihuana is likely to be palliative or provide therapeutic benefits for the symptoms or effects of

applicant’s condition. This is not a prescription for the use of medical marihuana. Additionally, if the patient

ceases to suffer from the above identified debilitating condition, I hereby certify I will notify the department in

writing.

__________________________________________________________________________

_____________________

Physician’s Signature

Date

Provide the name and telephone number of contact person at the physician’s office to verify validity of certification:

(

)

(Name – Please Print)

(Telephone Number)

Form Dlara/mmp-500 - Instructions For Applying For A Medical Marihuana Registry Identification Card/form Dlara/mmp-010 - Application Form For Registry Identification Card/etc. Page 3

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