Instructions And Form For Applying For A Renewal Medical Marihuana printable pdf download

Department of Licensing and Regulatory Affairs

DLARA/MMP-503 (4/11)

Michigan Medical Marihuana Registry

P.O. Box 30083

Lansing, MI 48909

Instructions for Applying for a

RENEWAL

Medical Marihuana Registry Identification Card

To renew your Michigan Medical Marihuana Registry ID card, you must complete the renewal application

packet and submit the following together in one envelope:

 RENEWAL APPLICATION FORM FOR REGISTRY IDENTIFICATION CARD



REQUIRED: Complete Section A: APPLICANT/PATIENT INFORMATION

o Required if Patient’s Name Change is selected, clear copy of supporting documents (I.e.,

Marriage License, Divorce Decree, etc.)



IF APPLICABLE: Complete Section B: PRIMARY CAREGIVER

o Required if you are designating a new caregiver or continuing with your current 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

o Required if Caregiver’s Name Change is selected, clear copy of supporting documents (I.e.,

Marriage License, Divorce Decree, etc.)



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 PHOTO IDENTIFICATION

 NEW PHYSICIAN CERTIFICATION FROM MICHIGAN LICENSED MD/DO



Your physician must complete and sign the Physician Certification form. This must be submitted

with your renewal application. DO NOT send or have medical records sent to the registry program.

 NEW CAREGIVER ATTESTATION and COPY OF CAREGIVER’S PHOTO IDENTIFICATION



Required if you are designating a caregiver in Section B

 $100.00 RENEWAL 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 RENEWAL APPLICATION FOR YOUR FILES

 SEND ALL REQUIRED DOCUMENTS TOGETHER IN ONE ENVELOPE TO THE ADDRESS AT THE

TOP OF THIS FORM



Do not send any documentation separately from the renewal application.



Your renewal application will be approved or denied within 15 days of receipt by the department.

If determined incomplete, your renewal application will be denied and you will receive a certified letter from

the State of Michigan. You can then resubmit a copy of your renewal 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 renewal application.

If approved, your renewal 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 renewal application.



If the information provided on the renewal application is determined to be false at any time, your registration card

will become null and void.

If you have questions, contact the Michigan Medical Marihuana Registry Program at (517) 373-0395.

Instructions And Form For Applying For A Renewal Medical Marihuana

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