Washington State Medical Marijuana Authorization Form
ADVERTISEMENT
1
2Medical Marijuana Program
P.O. Box 47852 | Olympia, WA 98504-7852
Telephone: 360-236-4819 | Fax: 360-236-2901
Washington State Medical Marijuana Authorization Form
Patient and Designated Provider Information
Full Legal Name of Patient
Full Legal Name of Designated Provider (if any)
Street Address
Designated Provider Street Address
City
State
City
State
Patient’s Date of Birth
ZIP Code
Designated Provider’s Date of Birth
ZIP Code
Authorizing Healthcare Practitioner Information
Name of Healthcare Practitioner (as appears on license)
Healthcare Practitioner License No. (Ex. – MD00001111)
Business Street Address for Healthcare Practitioner
City, State and ZIP Code for Healthcare Practitioner
Telephone number for Healthcare Practitioner where this authorization can be verified during normal business hours
Attestation of Healthcare Practitioner
I am licensed in the state of Washington and have diagnosed the above named patient as having the following terminal
or debilitating medical condition that is severe enough to significantly interfere with the patient’s activities of daily living
and ability to function, and can be objectively assessed and evaluated (check all that apply):
Cancer
Glaucoma
HIV
Crohn’s disease
Epilepsy or other seizure disorder
Multiple sclerosis
Spasticity disorder
Hepatitis C
Intractable pain
Chronic renal failure requiring hemodialysis
Posttraumatic stress disorder
Traumatic brain injury
A disease that results in nausea, vomiting, wasting, appetite loss, cramping, seizures, muscle spasms or spasticity
I further attest that I have performed an in-person examination of the above named patient and assessed his or her
medical history and medical condition. I have advised this patient about the potential risks and benefits of the medical
use of marijuana. It is my professional opinion that this patient may benefit from the medical use of marijuana.
Healthcare Practitioner Signature
Date Issued
Expiration Date
OPTIONAL: In my professional opinion, the medical needs of this patient exceed the presumptive number of plants
allowed by law. I recommend this patient be allowed to grow up to
plants (not to exceed 15) in his or her domicile
for his or her personal use. (Note: This provision applies only after July 1, 2016, and requires the patient and designated
provider, if any, to be entered into the medical marijuana authorization database and hold a recognition card.)
Health Care Practitioner Signature (if recommending additional plants)
DOH 630-123 June 2015
Page 1 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business