Instructions for Applying for a Medical Marijuana Registry Identification Card In CO.

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Instructions for Applying for a Medical Marijuana Registry Identification Card In COLORADO.

You must complete the Application for Identification Card form and ask your physician to complete the Physician Certification form. If the applicant is a minor or you have more questions, please contact the Registry at (303) 692-2184.
Before sending materials, please make sure your application packet is complete. Incomplete applications will be returned to the applicant.

APPLICATION FOR IDENTIFICATION CARD
Please complete the entire application form.
You may choose to designate caregiver, although you do not have to. A caregiver is defined as "a person, other than the patient and the patient's physician, who is eighteen years of age or older and has significant responsibility for managing the well-being of a patient who has a debilitating medical condition."
Complete the physician information
Sign and date the application

PHYSICIAN CERTIFICATION
Your physician must complete and sign the physician certification form
Only an MD or DO licensed to practice medicine in the state of Colorado may sign this form
The Registry must receive your complete application within 60 days of the physician's signature
A LEGIBLE PHOTO COPY OF A PHOTO ID THAT ESTABLISHES COLORADO RESIDENCY
(driver's license, state ID)

NON-REFUNDABLE $90.00 APPLICATION FEE
(check or money order payable to CDPHE)

SEND ALL OF THE ITEMS ABOVE TO:
Colorado Department of Public Health and Environment
Medical Marijuana Registry
HSVRD-MMP-A1
4300 Cherry Creek Drive South
Denver, Colorado 80246-1530

The information you provide will be verified within 30 days of receiving all the application materials. If approved, your card will be issued within 5 days after verification. The maximum time is 35 days between receipt of the completed application and issuing or denying the identification card.

The applicant will receive one card with the patient's information and caregiver information, if designated. The caregiver will not receive a card.

Keep copies of all the documents you submit to the Registry. For proof that your application has been submitted, you may want to send your application in by certified mail.

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Medical Marijuana Registry Application Form
1. Last Name (as it appears on your ID) 2. First Name (as it appears on your ID) 3. Middle Initial
4. Mailing Address 5. City 6. Zip Code State 7. County

8. Social Security Number
_ _
9. Date of Birth
/ /
10. Telephone Number
11. e-mail Address*
12. Gender
M () F ()
13. Are you homebound?
Yes () No ()
14. Provider of medical
marijuana: Select one of
the following that best
describes your intended
source of medical
marijuana:
() Self (skip the “Provider” section below)
() Care-giver (Required: enter name and address below)
() Medical Marijuana Center (Required: enter name and address below)
() Self and Care-giver (Required: enter name and address below)
() Self and Medical Marijuana Center (Required: enter name and address below)
16a. Name of Medical Marijuana Center (skip this field if using a care-giver)
16b. Mailing Address of Medical Marijuana Center 16c.City 16d.State 16e. Zip Code
Giver - Care
(ID required)
Medical Marijuana
Center
* I consent for communications from the Registry via e-mail
16f. Telephone Number
This is the first time I’ve applied in Colorado. I have been on the Colorado Registry before.
17a. Last Name of Care-Giver(as it appears on ID) 17b. First Name (as it appears on ID) 17c. Middle Initial
17d. Mailing Address 17e. City 17f. State 17g. Zip Code
17h. Date of Birth
/ /
17i. Telephone Number
17j. Alternate Number


APPLICANT
ID Required
18. Last Name 19. First Name 20. Middle Initial
21. Mailing Address 22. City 23.State 24. Zip Code
25. Telephone Number 26. Fax Number
WARNING! THE USE, POSSESSION, DISTRIBUTION, AND MANUFACTURE OF MARIJUANA REMAINS A FEDERAL CRIME IN
COLORADO, AND POSSESSION OF A REGISTRATION CARD PROVIDES NO PROTECTION WHATSOEVER AGAINST FEDERAL
CRIMINAL PROSECUTION.
I hereby certify that the above information is correct and complete.
27. Applicant’s Signature:
28. Date Signed:
The Applicant’s Signature has been subscribed and affirmed before me in the county of ____________________________, State of Colorado,
this __________ day of _____________________, 20_____.
__________________________________________________ ____
(Notary’s Official Signature)
__________________________________________________ ____
(Commission expiration date)

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PATIENT’S AND CAREGIVER’S PROOF OF IDENTITY AND PROOF OF RESIDENCY IN COLORADO

At least 1 of the following
Colorado Driver’s License
Colorado ID
Temporary Colorado Driver’s License
Temporary Colorado ID
Or at least 2 of the following
Minimum of 1 from the group of ID’s below -
Out of State Driver’s License
Out of State ID
Passport, Military ID, Tribal ID
And a Minimum of 1 from the group below -
Colo Work Identification/paycheck stub/W-2
Utility bill, medical/insurance bill or cable bill
The above items must show a Colorado residence

All Documents must be currently valid!
At least one of these documents must show the applicant’s date of birth.

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Medical Marijuana Registry Application Form

PHYSICIAN CERTIFICATION

Instructions: Please complete all the information required on this form OR provide relevant portions of the patient’s
medical record that contain all the information required on this form. Sign the form, and keep a copy in the patient’s
medical record. The patient will submit this certification along with his or her application for a Medical Marijuana
Registry identification card. This does not constitute a prescription for marijuana. WhIteout and cross-outs
WIll voId thIs form. You may contact the Registry at (303) 692-2184 if you have any questions or concerns.
PATIENT INFORMATION
1. NAME (LAST, FIRST, MI): 2. DATE OF BIRTH:
3. DATE OF PHYSICAL EXAMINATION FOR THE PURPOSE OF MEDICAL MARIJUANA RECOMMENDATION:
4. HOW MANY TIMES DURING THE PREVIOUS 12 MONTHS HAVE YOU SEEN THIS PATIENT?
5. ARE YOU AVAILABLE TO PROVIDE FOLLOW-UP CARE FOR THIS PATIENT?
6. RECOMMENDED DATE FOR FOLLOW-UP CARE VISIT?
7. IN YOUR OPINION, IS THIS PATIENT HOMEBOUND?
PHYSICIAN INFORMATION
8. NAME (LAST, FIRST, MI): 9. TELEPHONE NUMBER:
10. MAILING ADDRESS: 11. FAX NUMBER
12. CITY, STATE, AND ZIP CODE: 13. PHYSICIAN LICENSE NUMBER
DR-
14.
PHYSICIAN’S STATEMENT
15. The above-named patient has been diagnosed with and is currently undergoing treatment for the following chronic debilitating
medical condition: (Check appropriate boxes.)
16. Comments: (if no comments, the Registry recommends crossing through this area to prevent the addition of comments after your
signature)
I hereby certify that I am a physician duly licensed in good standing to practice medicine in Colorado, and tht I have a bona fide physician-patient relationship with the above-named patient. I have assessed this patient’s medical history and current medical condition, and I conclude that this patient may benefit
from the medical use of marijuana. This assessment is not a prescription for the use of marijuana.
17. PHYSICIAN’S SIGNATURE: 18. DATE:
Rev. July 2010
PHYSICIAN CERTIFICATION
MM/DD/YYYY
() Yes () No
MM/DD/YYYY
() Yes () No
a. () Cancer
b. () Glaucoma
c. () HIV or AIDS positive
OR a chronic or debilitating disease or medical condition that
produces, for this patient, one or more of the following and which,
in the physician’s professional opinion, may be alleviated by the
medical use of marijuana.
d. () Cachexia
e. () Severe pain (Required: What is the etiology of the pain?)
_______________________________ () Unknown
Note to physician: The etiology is required by law whenever severe
pain is selected.
f. () Severe nausea
g. () Seizures (including those characteristic of epilepsy)
h. () Persistent muscle spasms (including those characteristic
of multiple sclerosis)
MM/DD/YYYY
WhIteout and cross-outs WIll voId thIs form.
Medical Marijuana Registry Application Form
Note to physician: The Registry requires a copy of your current DEA certification to be on file with the Registry. If you have not
already provided this, FAX a copy to 303-758-5182 to prevent delays in processing this application.

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• Incomplete applications will be returned to the applicant.
• The date the patient signs and the physician signs do not have to be the same.
• Keep copies of all the documents you submit to the Registry. The law states “patients must reside in Colorado and submit the completed application
form adopted by the State Health Agency.” No one is permitted to submit paperwork to the Registry except the patient. For proof that your application
has been submitted, you may want to send your application in by certified mail.
• The applicant will receive one card with the patient’s information and caregiver information, if designated.
• Please check our web site to find the latest time estimate for processing applications.
• Available Primary Care-givers: The Registry will be accepting the names of individuals who would like to be a primary care-giver and have authorized the
Registry to release their contact information to patients in search of a primary care-giver. This is an optional service for those patients having difficulty
finding a primary care-giver. ase check our web site for the availability of this option. this service is available, a Request for Primary Care-giver
List form will be posted.
For more information, please visit:

Colorado:
Department of Public Health and Environment, Colorado Medical Marijuana Registry

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$10 Off Your Next Visit
Present this coupon on your next visit and receive $10 off a MMJ evaluation. Offer not valid with any other coupon or discount offer. See location for details
Expiration: 12-31-2011
Omm Alternative
3611 Galley Rd, Colorado Springs, CO 80909
Call Omm at (719) 581-9OMM (9666)
http://ommalternative.com/Welcome.html

Just if ya are in the colorado springs, Colorado area and wanna stop by OMM..save yourself 10 bucks on the Doctors visit.

Print and present..Have a Great Day and Keep on TOKIN.

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I WILL BE KEEPING THIS INFO UPDATED EVERY 3 DAYS, I WILL KEEP YOU ALL INFORMED ON ANY CHANGES AS WILL ADMIN AND MODERATORS.

iF YOU WOULD LIKE THE COMPLETE APPLICATION AND INFO NEEDED TOO COMPLETE PLEASE FEEL FREE TOO DROP ME AN EMAIL AT:

ICCM.WEEDWATCH@GMAIL.COM
(COPY AND PASTE INTO YOUR EMAIL.)

i WILL BE HAPPY TOO EMAIL YOU A COPY WITH ALL MATERIALS REQUIRED.


THANK YOU FOR YOUR TIME ...YOUR LOCAL COLORADO SPRINGS, COLORADO ADVOCATE

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So im curious where this treads gonna head..please poll on the subject. It be very apperciated.

[hippie420]

Seems pretty complete only thing I can imagine useful to add would be and one could just google this info would be the length of time in which it take to become a CO Resident for an out of stater moving. And as is with most Medical Marijuana law I assume a bonafide or minimum of 6 Month relationship with a physician pertaining to the particular cause of wanting medical marijuana and even possibly attempting alternative treatments before even being eligible for MMJ in CO.

Thanks for the info ICCM as I've been giving serious thought to moving to CO and attempt to acquire a MMJ card. I Live in a MMJ state but AIDS, Cancer, and MS are about all that is accepted.
Is Adult ADD acceptably treated by MMJ in CO? I mean it also helps with my back, neck, and leg pains, but I mostly medicate for the ADD and to have fun.

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If theres a will, theres a way. Been here less than 4 months, got all paperwork needed, still havent gotten my denail letter. Been buying and growing since day 1. No 6 month relationship with doctor required. Seen by doctor at OMM, have exsisting paperwork from another doctor, well long story short, <<<Legal as far as the state sees it now, will let you know different if denail paperwork comes. If you have any concerns I ask you drop me an email and I will try and walk you through anything you might need. Thanks for the input.