Change Of Patient Records - Medical Marijuana Registry
Download a blank fillable Change Of Patient Records - Medical Marijuana Registry in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Change Of Patient Records - Medical Marijuana Registry with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Medical Marijuana Registry
CR
4300 Cherry Creek Drive South, Denver, CO 80246-1530 303-692-2184
E-mail: medical.marijuana@state.co.us Website:
Change of Patient Records
Instructions:
1.
Complete all required sections of the form neatly and accurately.
2.
Do not submit this form unless you have an active registration card.
3.
There are no fees to file this form. DO NOT send money with this form. All monies received at the Registry are
nonrefundable.
4.
Do not write-over, cross-out, or use white-out on this form, or it will be voided. If you make a mistake on the form,
please complete a new one.
5.
After completing the form, you must sign and date it in front of a notary and have it notarized.
Include a copy of your valid ID. The primary parent’s or guardian’s ID is required for paperwork submitted for patients
6.
under the age of 18. The chart below lists the Registry’s preferred documents:
PROOF OF IDENTITY
The Registry requires a verifiable ID for all forms. Please submit one of the following IDs with your form:
Colorado Driver’s License
Out-of-state Driver’s License
Colorado ID
Out-of-state ID
Temporary Colorado Driver’s License
U.S. Passport or passport card
Temporary Colorado ID
Military ID (copy of front and back)
Tribal ID
If you do not have the above documents, please contact the Registry at 303-692-2184 (ext. 3) to discuss other options.
i.
All documents must be currently valid when received at the Registry.
ii.
Damaged, expired, or tampered IDs are not valid.
iii.
Passports must include full photo page and signature page. Passport cards must include copy of front and back.
iv.
The address on the ID does not have to match the mailing address on the form.
v.
All IDs must be verifiable and have specific issue and expiration dates.
The ID must show the patient’s date of birth.
vi.
7.
You may only change your caregiver or medical marijuana center one time per month.
8.
Patient social security numbers are used to confirm identity and protect confidentiality.
9.
Incomplete forms will be rejected. A form is considered complete when:
a.
The form is completed, signed and notarized.
A copy of the patient’s ID is included.
b.
A copy of the caregiver’s ID and form #MMR1012 Caregiver Acknowledgment are included, if the form has
c.
caregiver information.
10. Forms must be sent separately, one form per envelope.
11. Make a copy of all your paperwork for your files.
12. You must submit paperwork within ten (10) days of the date you have it notarized.
13. The Registry does not print new cards for changes of address, medical marijuana center or caregiver (unless the patient is
homebound or under the age of 18).
14. The primary parent or legal guardian’s signature is required on all forms for patients under the age of 18.
15. Authorized Representatives –If patient care rights and responsibilities have been legally assigned to another person, a
copy of the legal documentation must be on file with the Registry. Acceptable documents include court-certified
guardianship documents, power of attorney or medical power of attorney. Medical care rights must be included as a
responsibility of the guardian/agent in order to contact the Registry regarding patient records and care. A copy of the
guardian/agent’s ID is also required.
16. Please allow 4 to 6 weeks from the date the Registry receives your paperwork for processing. If your form is rejected or
a new card is required, you should receive a letter or card within 6 weeks. Your paperwork or card will be mailed to the
address on your paperwork. Cards cannot be mailed out of state, to a third party or sent “in care of” another party.
17. Submit paperwork by mail or deliver to the Registry’s drop-box. The Registry does not accept forms by fax or e-mail.
Mail to:
Drop-Box:
Change Request
710 S. Ash Street, South East Entrance
CDPHE
Open: Monday-Friday, 7:00 a.m. to 6:00 p.m.
HSV-8608
The drop box is on the wall inside the first set of glass doors. Your paperwork
4300 Cherry Creek Drive South
must be in a sealed envelope. You will not receive a receipt. If you wish to
Denver, CO 80246-1530
have a receipt, please mail in your paperwork by certified mail.
For more information, visit our website
or call 303-692-2184.
MMR1003 – Change Form – Revised January 2014
Page 1 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical