Washington State Medical Marijuana Authorization Form (Page 2 of 2) in pdf

Medical Marijuana Program

P.O. Box 47852 | Olympia, WA 98504-7852

Telephone: 360-236-4819 | Fax: 360-236-2901

Patient/Designated Provider Notification

An authorization for the medical use of marijuana does not provide protection from arrest unless the patient and

designated provider, if any, are entered into the medical marijuana authorization database and hold a recognition card.

An authorized patient or designated provider may not:



Sell, donate, or otherwise supply the patient’s marijuana to another person.



Use or display marijuana in a manner or place that is open to the view of the general public.



Grow, possess, or use marijuana on federal property.



Grow more than 15 plants in any one housing unit even if multiple qualifying patients or designated providers

reside in the housing unit.



Grow, store, produce, or process marijuana or marijuana-infused products if any portion of such activity can be

readily seen by normal unaided vision or readily smelled from a public place or the private property of another

housing unit.

Patient/Designated Provider Attestation

Patient: I hereby attest that I have discussed the risks and benefits of the medical use of marijuana with my healthcare

practitioner. I understand some of the risks may include possible long-term effects to the brain in the areas of memory,

coordination, and cognition; impairment of the ability to drive or operate heavy machinery; physical or psychological

dependence; and respiratory damage if smoked. I further attest that I have read chapter 69.51A RCW and understand

the legal requirements of being a patient.

Designated provider: I hereby attest that I am over the age of 21 and agree to serve as the designated provider for the

patient identified on this form. I understand I can serve as the designated provider for only one patient at a time. I

further understand that I can stop serving as designated provider for this patient by revoking the designation in writing.

The revocation must be signed, dated, and provided to the patient and the medical marijuana authorization database

administrator if I am entered into the database. I understand 14 days must elapse before I can begin serving as the

designated provider for a different patient. I further attest that I have read chapter 69.51A RCW and understand the

legal requirements of being a designated provider.

Signature of Patient or Designated Provider

Date

NOTE – In order to be valid this authorization must be:



Fully completed and printed by the authorizing healthcare practitioner. Every field must be filled unless it is described as

“optional.” If a designated provider is not identified, those fields must be marked N/A.



Printed on tamper-resistant paper as defined in RCW 69.51A.010.



Written on this form (or a subsequent version) for NEW authorizations and renewals beginning July 24, 2015.



Written on this form (or a subsequent version) for ALL authorizations beginning July 1, 2016.

Authorizations expire after one year for adult patients and six months for patients under the age of 18. The authorizing

healthcare practitioner may indicate an earlier expiration date. A copy must be kept in the patient’s medical record.

The patient and designated provider, if any, must obtain individual authorizations from the authorizing healthcare

practitioner. It is not sufficient for the designated provider to possess a copy of the patient’s authorization.

For questions contact the Medical Marijuana Program at

medicalmarijuana@doh.wa.gov

or (360) 236-4819, or visit the

Department of Health’s website at

DOH 630-123 June 2015

Page 2 of 2

Washington State Medical Marijuana Authorization Form Page 2

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