Patient E-Mail And Acknowledgement Form - Minnesota (Page 2 of 2) in pdf

purpose of reporting on the benefits, risks and outcomes regarding patients with a qualifying medical

condition engaged in the therapeutic use of medical cannabis.

Requirements to Provide

You are not legally required to provide any of the requested information.

Consequences of Supplying or Refusing to Supply Information

Providing the information requested by the patient registry may result in you being determined eligible

to participate in the medical cannabis patient registry program. Enrollment in the patient registry is

required in order for medical cannabis to be distributed to you. However if you choose to not provide all

the required information, we will be unable to create your medical cannabis patient registry account

and you will not be able to enroll in the medical cannabis program. Minnesota Statute section 152.27,

subdivision 3 requires that applications for enrollment in the medical cannabis patient registry be

completed on a form prescribed by the Commissioner of Minnesota Department of Health and certain

minimum information may be required. Failure to provide any of the requested information could result

in the delay or possible denial of your initial or renewal application and of your ability to participate in

the medical cannabis program.

Other Persons or Entities Authorized to Receive Your Information

The health care practitioner who certifies your qualifying medical condition for the purposes of the

patient registry is required by law to report to MDH your health records related to the qualifying

medical condition. The health care practitioner may release these records to MDH without your written

consent.

Pharmacists at registered Cannabis Patient Centers in Minnesota may access information in the patient

registry in order to determine the appropriate composition and dosage of medical cannabis.

Law enforcement officials may only access the information I provide to the medical cannabis patient

registry if they first get a search warrant.

Acknowledgement

I have read and understand this notice and the intended use of the information I and my health care

practitioner provide to the patient registry.

________________________________________

________________________________

Signed

Date

Patient E-Mail And Acknowledgement Form - Minnesota Page 2