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DCH/MMP-500 (Rev. 3/10)
  Michigan Department of Community Health Michigan Medical Marihuana Registry
 
P.O. Box 30083         Lansing, MI 48909           www.michigan.gov/mmp
 
Instructions for Applying for a Medical Marihuana Registry Identification Card
To be eligible for the Michigan Medical Marihuana Registry, you must complete the application packet and submit the following information:
APPLICATION FORM FOR REGISTRY IDENTIFICATION CARD
 
REQUIRED: Complete Section A: APPLICANT/PATIENT INFORMATION
IF APPLICABLE: Complete Section B: PRIMARY CAREGIVER
  Required if you are designating a caregiver
  "Primary caregiver" means a person who is at least 21 years old and who has agreed to assist with a patient's medical use of marihuana and who has never been convicted of a felony involving illegal drugs
 
REQUIRED: Complete Section C: PERSON ALLOWED TO POSSESS PATIENT’S MARIHUANA PLANTS
REQUIRED: Complete Section D: CERTIFYING PHYSICIAN INFORMATION
REQUIRED: Section E: ATTESTATION, SIGNATURE, & DATE
  The Patient must sign and date the application
PHYSICIAN CERTIFICATION FROM MICHIGAN LICENSED MD/DO
  Your physician must complete and sign the Physician Certification form. This must be submitted with your application. DO NOT send or have medical records sent to the registry program.
CAREGIVER ATTESTATION
  Required if you designated a caregiver in Section B
COPY OF CAREGIVER’S CURRENT PHOTO IDENTIFICATION (IF APPLICABLE)
COPY OF PATIENT’S CURRENT PHOTO IDENTIFICATION
$100.00 APPLICATION FEE or $25.00 APPLICATION FEE if patient is currently enrolled in Medicaid or receiving SSI or SSD, and submits the appropriate supporting documents
  Check or money order only. Make payable to “State of Michigan—MMMP.” Do not send cash.
COPY OF DOCUMENTATION VERIFYING RECEIPT OF BENEFITS, IF SUBMITTING $25.00 FEE
  Acceptable: Disability or SSI award letter, Social Security Administration document verifying receipt of disability benefits, FULL Medicaid Only: MI Health card or other health plan card
  NOT ACCEPTABLE: Medicare card, Bridge card, Bank statements, Social Security IRS Form 1099, Social Security yearly benefits statement, VA disability
RETAIN A COPY OF YOUR APPLICATION FOR YOUR FILES
  These are proof that your application is in process.
SEND ALL REQUIRED DOCUMENTS TOGETHER IN ONE ENVELOPE TO THE ADDRESS AT THE OP OF THIS FORM:
  Do not send any documentation separately from the application.
  Your application will be approved or denied within 15 days of receipt by the department.
 
  If determined incomplete, your application will be denied and you will receive a certified letter from the State of Michigan. You can then resubmit a copy of your application with all required documents for reconsideration without an additional fee (unless you were denied for an insufficient fee) for up to one year from receipt of your denied application.
  If approved, your application will be processed in the date order received. The patient, and if applicable, the caregiver, will then be issued and sent a registry ID card to the mailing address provided on your application.
  If the information provided on the application is determined to be false at any time, your registry ID card will become null and void.
  If you have questions, contact the Michigan Medical Marihuana Registry Program at (517) 373-0395.
   
 
DCH/MMP-010 (Rev. 3/10)
FOR OFFICIAL USE ONLY
Michigan Department of Community Health
Michigan Medical Marihuana Registry
P.O. Box 30083
Lansing, MI 48909
www.michigan.gov/mmp
  APPLICATION FORM FORREGISTRY IDENTIFICATION CARD
   
  INSTRUCTIONS: Please complete all required information to comply with the registration requirements of the Michigan Medical Marihuana Registry. Attach readable copies of photo ID(s) and your registration fee. The registration fee for this application is $100.00 or $25.00 if the patient is enrolled in Medicaid or receiving SSI or SSD (copies of qualifying documentation must be attached). Enclose your check or money order made payable to State of Michigan—MMMP. We do not accept Cash, Credit Cards, or Debit Cards.
PLEASE TYPE OR PRINT LEGIBLY
 
  Section A:    APPLICANT/PATIENT INFORMATION: (REQUIRED)
   
 
First Name : Last Name : Gender :
Male Female
 
Date Of Birth :  
MAILING ADDRESS PHONE NUMBER :  
 
CITY : STATE MI : ZIP CODE : ALTERNATE PHONE NUMBER
  Photo Identification: A clear photocopy of one of the following must be attached. Please check appropriate box:
 
MI Driver’s License or MI ID Card # OTHER
   
 
  Section B:    PRIMARY CAREGIVER: (IF APPLICABLE)
   
 
First Name : Last Name : Gender :
Male Female
 
Date Of Birth :  
MALLING ADDRESS TELEPHONE NUMBER :  
 
CITY : STATE MI : ZIP CODE : ALTERNATE PHONE NUMBER
  Photo Identification: A clear photocopy of one of the following must be attached. Please check appropriate box:
 
MI Driver’s License or MI ID Card # OTHER
   
 
  Section C:    PERSON ALLOWED TO POSSESS PATIENT’S MARIHUANA PLANTS: (REQUIRED)
   
 
SELECT ONE : APPLICANT/PATIENT OR PRIMARY CAREGIVER* (Caregiver Attestation & photo ID Required)
   
 
DCH/MMP-020 (3/10)
  Michigan Department of Community Health Michigan Medical Marihuana Registry
P.O. Box 30083         Lansing, MI 48909           www.michigan.gov/mmp
 
DCH/MMP-030 (Rev. 3/10)
  Michigan Department of Community Health Michigan Medical Marihuana Registry
 
P.O. Box 30083         Lansing, MI 48909           www.michigan.gov/mmp
INSTRUCTIONS: Please complete all required information in order to comply with the requirements of the Michigan Medical Marihuana Registry.
Caregiver Attestation
PLEASE TYPE OR PRINT LEGIBLY
 
   DECLARATION: (REQUIRED)
   
 
I CAREGIVER’S NAME (PRINTED) , do hereby declare:  
 
that I am willing and able to serve as the primary caregiver for:
 
PATIENT’S NAME (PRINTED)  
   
 
   I further certify that:
   
 
I am at least 21 years of age
I have never been convicted of a felony offense involving illegal drugs
I understand that my caregiver registration will become null and void if I am convicted of a felony offense involving illegal drugs
I am a caregiver for no more than 5 patients
I have submitted a copy of my photo ID to my qualifying patient to submit with this application
 
    SOCIAL SECURITY NUMBER & DATE OF BIRTH: (REQUIRED)
 
DATE OF BIRTH
     PRIMARY CAREGIVER INFORMATION: (REQUIRED)
   
 
MAILING ADDRESS TELEPHONE NUMBER
 
CITY : STATE : ZIP CODE : TELEPHONE NUMBER
       OTHER NAMES USED-including maiden names for females: (REQUIRED, IF APPLICABLE)
     Attach a separate page if more space required
 
First Name Midle Name Last Name
   
 
First Name Midle Name Last Name
   
 
First Name Midle Name Last Name
 
Not readable? Change text.


   
  I understand that it is necessary to secure a criminal conviction history as part of the screening process. I authorize this agency to use the information provided in this application to obtain a criminal conviction history file search from the Central Records Division of the Michigan Department of State Police or other law enforcement or judicial recordkeeping organization to verify if I have been convicted of any felony offenses involving illegal drugs. The statements in this application are true and correct. I have not withheld information that might affect the decision to be made on this application. In signing this application, I am aware that a false statement or dishonest answer may be grounds for denial of my application or revocation of my registration and that such misrepresentation is punishable by law.
   
   
 
 
 
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