Medical Marijuana Program APPLICATION/RENEWAL (Please … - marijuana medical card application form

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• (1) application for medical marijuana card
• (2) medical marijuana renew card application
• (3) medical marijuana doctor form
• (4) how to renew medical marijuana card

State of California--Health and Human Services Agency Department of Health Services
Medical Marijuana Program
APPLICATION/RENEWAL
(Please Print)
For application instructions, view page 4.
This application is for:
Patient Only (Applicant) Primary Caregiver Only Patient and Primary Caregiver
SECTION 1 TO BE COMPLETED BY ALL APPLICANTS.
Name (last, first, middle initial)
Mailing address (number, street) Telephone number
( )
City State ZIP code County of residence
Additional contact information
Is applicant under 18 years of age? Yes No
If yes, complete Section 2 for the parent, legal guardian, or person with legal authority to make medical decisions for minor applicant, unless
minor applicant is (check one):
Lawfully emancipated; or Declares self-sufficient minor status or is a minor capable of medical consent
SECTION 2 TO BE COMPLETED FOR MINOR APPLICANT IDENTIFIED IN SECTION 1.
Parent/guardian/other name (last, first, middle initial) Telephone number if different from above
( )
Mailing address if different from above (number, street) City State ZIP code
Relation to applicant (check one):
Parent with legal authority to make medical decisions
Legal Guardian
Other person or entity with legal authority to make medical decisions
SECTION 3 TO BE COMPLETED IF THE APPLICANT IS UNABLE TO MAKE HIS/HER OWN MEDICAL DECISIONS.
Does the applicant have the capacity to make medical decisions? Yes No
If "No," enter the name and address of person acting on the applicant's behalf:
Name (last, first, middle initial) Telephone number
( )
Mailing address (number, street) City State ZIP code
Check one of the following to indicate the legal authority of the person (legal representative) signing this application on behalf of the
applicant:
I am the conservator for the applicant and I have authority to make medical decisions.
I am an attorney-in-fact under a durable power of attorney for health care.
I am a surrogate decision maker authorized under an advanced healthcare directive.
I am authorized by statutory or decisional law to make medical decisions for the applicant, as follows:
Parent Legal Guardian Other (please specify):
DHS 9042 (8/05) Page 1 of 4
SECTION 4 TO BE COMPLETED BY THE PRIMARY CAREGIVER REQUESTING AN IDENTIFICATION CARD.
Name (last, first, middle initial) Date of birth (if less than 18 years of age)
Mailing address (number, street) Telephone number
( )
City State ZIP code County of residence
Primary Caregiver Duties: (Document how you consistently assume responsibility for the housing, health, or safety of the applicant.)
Check your designation as a primary caregiver from the following list:
I am the parent of the applicant or the person entitled to make medical decisions on behalf of the applicant.
I am the designated primary caregiver for only this applicant.
I am the designated primary caregiver for another applicant (qualified patient) in this county.
I am the designated primary caregiver for an applicant (qualified patient) in a different county.
County name:
Check one of the two following choices if your status as a primary caregiver is linked to a health related entity:
I am the owner/operator of a clinic pursuant to Chapter 1 (commencing with Section 1200), Division 2 of the Health and Safety (H&S) Code.
I am a clinic/facility/hospice or home health agency employee* designated by the owner/operator to serve as a primary caregiver.
Check all that apply:
This health care facility is licensed pursuant to Chapter 2 (commencing with Section 1250), Division 2 of the H&S Code.
This residential care facility is licensed pursuant to Chapter 3.01 (commencing with Section 1568.01), Division 2 of the H&S Code.
This residential care facility is licensed pursuant to Chapter 3.2 (commencing with Section 1569), Division 2 of the H&S Code.
This hospice or home health agency is licensed pursuant to Chapter 8 (commencing with Section 1725), Division 2 of the H&S Code.
* Health and Safety Code, Section 11362.7(d)(1), limits a maximum of three employees that may serve as primary caregivers. Note: Include a copy of this
page for each caregiver.
Primary Caregiver Declaration: I understand and acknowledge my assigned duties as the designated primary caregiver for
. I understand that if the applicant's identification card expires, then my primary caregiver
Applicant's name
identification card shall also expire. I agree to return my primary caregiver identification card to this county health department or its designee
if this applicant changes primary caregivers. I agree that if I am the owner or operator of a health care facility designated as the primary
caregiver of this applicant, that I shall notify this county health department or its designee if a change of primary caregivers is made. I
declare under penalty of perjury that the information I provided on this form is true and correct.
Printed name of primary caregiver
Signature of primary caregiver Date
DHS 9042 (8/05) Page 2 of 4
SECTION 5 ALL APPLICANTS MUST IDENTIFY THEIR ATTENDING PHYSICIAN.
Attending physician name California medical license number
Service mailing address (number, street) Licensed by (check one)
City State ZIP code Medical Board of California
Osteopathic Medical Board of California
Office telephone number Office fax number
() ()
Notice Required by Civil Code, Section 1798.17
The Civil Code, Section 1798.17, requires that this notice be provided when collecting personal or confidential information from
individuals. Providing the individual information and identifying information requested on this form is mandatory. Failure to
furnish this information to the administering agency, in order to process your application for a medical marijuana identification
card, will result in denial of your application. The information collected will be verified for accuracy to determine eligibility for a
medical marijuana identification card. Sections 11362.71 and 11362.715 of the Health and Safety Code authorize the
collection and maintenance of the information.
The Compassionate Use Act of 1996 (Act) (Health & Safety Code, Section 11362.5) ensures that patients and their primary
caregivers who possess or cultivate marijuana for the personal medical purposes of the patient upon the recommendation of a
physician are not subject to California criminal prosecution or sanction. However, the Act does not protect marijuana plants
from seizure nor individuals from federal prosecution under the federal Controlled Substances Act. The information that you
provide in this application may be released as required by law, judicial order, or subpoena, and could be used in a federal
criminal prosecution.
You have the right to access records containing your personal information which are maintained by the county health
department, or the county's designee, and the Department of Health Services.
Responsibilities
It is my responsibility:
z To notify, within seven days, the county health department or the county's designee of any changes in my attending
physician or designated primary caregiver.
z To use my identification card only for the purposes intended by the law.
z To ensure that an authorized medical release of information is on file with my medical provider in order to complete my
application.
Declaration
I have read the notice required by Civil Code, Section 1798.17 and understand my responsibilities as stated above concerning
my participation in the Medical Marijuana Program. I confirm to the best of my knowledge the listed duties and information
provided by my primary caregiver. I declare under penalty of perjury that the information I provided on and with this application
is true and correct.
Print name of applicant or legal representative
Signature of applicant or legal representative Date
DHS 9042 (8/05) Page 3 of 4


What is a medical cannabis card? These cards are issued by a state or country in which medical cannabis is recognized. Typically a patient is required to pay a fee to the state in order to obtain a medical marijuana card.

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