Change Of Patient Records - Medical Marijuana Registry Page 2
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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:
STAFF
Change of Patient Records
ONLY
See instructions on page 1. Proof of identification required with all forms.
Yes
No
Is the patient homebound?
1. Social Security Number (optional)
Section A: Patient Information
(Required)
-
-
The name on the form must match the legal name on your ID.
____________
2. Last Name
3. First Name
4. Middle Initial
Evaluated
5a. Mailing Address
5b. Apartment/Suite #
6. City
State
7. Zip Code
8. County
9. Date of Birth
10. Telephone Number
____________
-
-
(
)
-
CO
Data Entry
11. E-mail Address (optional)*
* By providing your e-mail address, you agree to receive communication from the Registry by e-mail
Change Request: Please mark all changes that apply. For each option selected, complete all blanks.
____________
12. Change my contact information. The above address and contact information is new.
Card Printed
13. Change my name. I have enclosed a copy of the certified, official document that proves my name change.
a. Last Name
b. First Name
c. Middle Initial
Old Name
d. Last Name
e. First Name
f. Middle Initial
New Name
g. I have included a copy of the following certified document to prove my name change:
Support
Marriage Certificate
Divorce Decree
Other court documents
Corrections:
Documentation
14. Caregiver as “Self.” Please remove the medical marijuana center and/or caregiver from my records.
15. Change my Medical Marijuana Center (MMC).
Please complete information based on the name of the
--
center as it appears on the Department of Revenue license. The retail name (dba) is preferable, if listed on the
license. Only homebound patients, or patients under age 18, may list both a caregiver and a MMC.
a. Name of Medical Marijuana Center
b. Dept. of Revenue License #
Medical
c. Mailing Address of the Medical Marijuana Center
d. Apartment/Suite #
Marijuana
Center
e. City
State
f. Zip Code
g. Telephone Number
Information
(
)
-
CO
16. Change of caregiver. To designate a primary caregiver, form #1012 Caregiver Acknowledgment must be
submitted with this change request. Only homebound patients, or patients under age 18, may list both a
caregiver and a medical marijuana center. Caregiver’s ID must be included with form.
a. Caregiver’s Last Name
b. Caregiver’s First Name
c. Date of Birth
Caregiver
-
-
Information
I hereby certify that the above information is correct and complete.
17. Patient’s or Authorized Representative’s Signature:
18. Date Signed: (mm/dd/yyyy)
The signature and proof of identity of the above individual was subscribed and sworn to before me in
_____________________ County, Colorado on this ________ day of _____________, 20____.
(County name)
(Day)
(Month)
______________________________________
(Notary’s official signature)
___________________________________
(Commission expiration date)
AFFIX NOTARY SEAL
MMR1003 – Change Form – Revised January 2014
Page 2 of 2
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