Medical Marijuana Program Qualifying Patient Checklist Please note that this checklist information and other instructions may change. Please refer back to the ADHS website for the most current information. Print out and review this checklist prior to submitting your Qualifying Patient Application in the ADHS online system. This checklist will assist you in compiling the required information and supporting documentation. Application requirements are also outlined in Arizona Administrative Code (A.A.C.) R9-17-202. You will be asked to enter the following information and submit the following supporting documents: 1. Application Information: □ The patient’s □ First name; middle initial, if applicable; last name; and suffix, if applicable □ Date of birth □ Gender □ The identifying number on the applicable card or document (see Section 2 below for list of identification requirements and options). The patient must also enter the ID type, issuing state, and issued date. □ The patient’s residential address and county. □ The patient’s phone number. □ The patient’s email address where confidential information can be sent (free email address website links are provided within the application). □ The patient’s mailing address. Patient can check box if same as residential address. □ The name, address, and telephone number of the physician attesting for the patient. This information must be obtained from the Medical Marijuana Physician Certification form. □ The physician’s license number, physician license state, and license type. This must be obtained from the Medical Marijuana Physician Certification form. □ The patient’s Qualifying Health Conditions that apply. This information must be obtained from the Medical Marijuana Physician Certification form. □ If the patient is designating a caregiver, the following caregiver information: □ First name; middle initial, if applicable; last name; and suffix, if applicable □ Date of birth □ Gender □ Address and county where caregiver resides □ Whether the patient is requesting authorization to cultivate marijuana plants. □ If the patient designated a caregiver, if the caregiver is requesting to cultivate marijuana plants. □ Whether the patient would like notification of any clinical studies needing human subjects for research on the medical use of marijuana. □ If the patient is eligible for the Supplemental Nutrition Assistance Program (SNAP), documentation required. □ If the patient is homeless, an address where the patient can receive mail. 2. Documentation Needed for Uploading The current photograph must be an image file (JPG, PNG, or GIF file format). The other supporting documents can be PDF documents or image files (JPG, PNG, or GIF file format). The recommended file type is PDF. The size of the each file should not exceed 2MB. □ A current photograph of the patient. Photograph must be taken no more than 60 calendar days before the submission of the application. Photograph must be capable of producing an image: Updated 4.13.11 azdhs.gov/medicalmarijuana 2 2 inches by 2 inches in size with minimum dimensions of 600x600 pixels and maximum dimensions of 1200x1200 pixels. In natural color That is a front view of the individual’s full face, without a hat or headgear that obscures the hair or hairline, with a plain white or off-white background That has between 1 and 1 3/8 inches from the bottom of the chin to the top of the head □ A copy of the patient’s: □ Arizona driver’s license issued on or after October 1, 1996; OR □ Arizona identification card issued on or after October 1, 1996; OR □ Arizona registry identification card; OR □ Photograph page in the patient’s U.S. passport; OR □ An Arizona driver’s license or identification card issued before October 1, 1996 AND one of the following: □ Birth certificate verifying U.S. citizenship □ U.S. Certificate of Naturalization □ U.S. Certificate of Citizenship □ Signed and dated Medical Marijuana Patient Attestation. This must be downloaded from the ADHS website
Posted on: Tue, 15 Oct 2013 18:45:48 +0000
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