Patient E-Mail And Acknowledgement Form - Minnesota printable pdf download

Minnesota Medical Cannabis Program

Patient E-Mail and Acknowledgement Form

Patient Name:

Patient Date of Birth (xx/xx/xxxx):

Enter the email address you want to use for the Minnesota Medical Cannabis Patient Registry:

Your email address: __________________________________________________________

This is the email address to which the Minnesota Department of Health will send you information to

complete your on-line application for enrollment in the Medical Cannabis Patient Registry.

The Medical Cannabis Patient Registry is a state program run through the Minnesota Department of

Health (MDH). When a government entity collects private information from a person, the entity must

give the person a Tennessen notice. The purpose of this notice is to enable you to make an informed

decision about whether to give information about yourself to the government entity.

Classification of Data Provided

The information contained in the medical cannabis patient registry is considered private data on

individuals, which means that data are not public but accessible to the individual subject of that data.

If you choose to create an

Your email address will serve as the user name during account registration.

online patient registry account, your user name, password and answers provided to security

questions as part of the registration process are also considered private data.

Purpose and Intended Use

The information requested by the medical cannabis patient registry will be used to communicate with

you, establish your eligibility and identity, and for MDH to evaluate information on patient

demographics, effective treatment options, clinical outcomes, and quality-of-life outcomes for the

Under Minnesota Statutes §152.28, subdivision 2, data collected on patients by a health care practitioner and reported to the patient registry

are health records under section 144.291, and are private data on individuals under section 13.02, but maybe used or reported in an aggregated,

nonidentifiable form as part of a scientific, peer-reviewed publication of research conducted under section 152.25 or in the creation of summary

data, as defined in section 13.02, subdivision 19. Under Minnesota Statute §152.31, government data in patient files maintained by the

commissioner and the health care practitioner, and data submitted to or by a medical cannabis manufacturer, are private data on individuals, as

defined in section 13.02, subdivision 12, or nonpublic data, as defined in section 13.02, subdivision 9, but may be used for purposes of complying

with chapter 13 and complying with a request from the legislative auditor or the state auditor in the performance of official duties.

Not public data maintained by the commissioner may not be used for any purpose not provided for in Minnesota Statutes, sections 152.22 to

152.37, and may not be combined or linked in any manner with any other list, dataset, or database.

Patient E-Mail And Acknowledgement Form - Minnesota