Fillable Printable Health Care Professional Verification Form - Vermont

Health Care Professional Verification Form - Vermont

State of Vermont Department of Public Safety

Marijuana Registry

[phone] 802-241-5115

103 South Main Street

[fax] 802-241-5230

Waterbury, Vermont 05671-2101

[email] DPS.VTMR@state.vt.us

www.dps.vermont.gov

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HEALTH CARE PROFESSIONAL VERIFICATION FORM

INSTRUCTIONS: This form must be completed by the patient applicant’s health care professional. This form must be

signed within the last 6 months to be acceptable. Failure to submit this completed form will render the patient’s

application incomplete. The definitions listed below are provided to assist the health care professional completing this

form.

DEFINITIONS:

“Bona fide health care professional-patient relationship” means:

A treating or consulting relationship of not less than six months duration, in the course of which a health care

professional has completed a full assessment of the registered patient’s medical history and current medical condition,

including a personal physical examination. The six-month requirement shall not apply if a patient has been diagnosed

with:

A) a terminal illness;

B) cancer with distant metastases; or

C) acquired immune deficiency syndrome.

A patient applicant may be approved, notwithstanding the six-month requirement, if the debilitating medical condition is of

recent or sudden onset and a previous health care professional was unable to verify the nature of the disease and its

symptoms.

“Health care professional” means an individual who is:

A) licensed as a physician or osteopathic physician under 26 V.S. A Chapter 23 or Chapter 33;

B) licensed as a naturopathic physician under 26 V.S.A. Chapter 81, who has a special license endorsement authorizing

the individual to prescribe, dispense, and administer prescription medicines to the extent that a diagnosis provided

by a naturopath under this chapter is within the scope of his or her practice;

C) certified as a physician’s assistant under 26 V.S. A. Chapter 31; or

D) licensed as an advanced practice registered nurse under 26 V.S.A. Chapter 28.

This definition includes professionally licensed individuals under substantially equivalent provisions in New

Hampshire, Massachusetts, or New York, except for naturopaths.

“Debilitating medical condition” means a disease, medical condition, or its treatment, that is chronic, debilitating, and

reasonable medical efforts have been made over a reasonable amount of time without success to relieve the symptoms,

for the following diagnoses:

A) cancer, acquired immune deficiency syndrome, positive status for human immunodeficiency virus, multiple

sclerosis; or

B) any other diagnoses that produces chronic, debilitating and severe, persistent and one or more of the following

intractable symptoms: cachexia or wasting syndrome, severe pain, severe nausea, or seizures.

A patient applicant without a “debilitating medical condition” is not eligible for a Marijuana Registry identification card.

THIS FORM MUST BE SUBMITTED WITH A PATIENT APPLICATION!

_____________________________________________________________________________________________

State of Vermont Department of Public Safety

Marijuana Registry

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HEALTH CARE PROFESSIONAL VERIFICATION FORM

The Marijuana Registry will contact the health care professional completing this form for the purposes of confirming the

accuracy of the information contained on this form.

ALL SECTIONS OF THIS FORM MUST BE COMPLETED

THIS FORM MUST BE SUBMITTED WITH A PATIENT APPLICATION!

PATIENT APPLICANT’S INFORMATION (Please print legibly)

Full Legal Name: Last ______________________________ First __________________________________ M.I. ________

Date of Birth: ______________________________ Telepho ne Num be r: _____________________________________

HEALTH CARE PROFESSIONAL INFORMATION (Please print legibly)

Full Legal Name: Last ___________________________________ First ________________________________ M .I . _____

Office Mailing Address: ________________________________________________________________________________

City, State, Zip: ____________________________________________ Telephone Number: _________________________

HEALTH CARE PROFESSIONAL LICENSE INFORMATION:

License Number: ______________________________ Issuing State (circle one): VT NH MA NY

LICENSURE CATEGORY

Doctor of Medicine Physician Assistant

Osteopathic Physician Advanced Practice Registered Nurse

Naturopathic Physician

VERIFICATION OF A D EBI LI T A TING ME DI CA L CO N DITION

I am not treating or consulting the patient applicant for a debilitating medical condition as defined.

I am treating or consulting the patient applicant for cancer.

I am treating or consulting the patient applicant for acquired immune deficiency syndrome.

I am treating or consulting the patient applicant for h um an im munodeficiency vi rus .

I am treating or consulting the patient applicant for multiple sclerosis.

I am treating or consulting the patient applicant for a disease, medical condition, or its treatment that is chronic,

debilitating, and produces severe, persistent and one or more of the following intractable symptoms: cachexia (wasting

syndrome), severe pain, severe nausea; or seizures. This selection REQUIRES the following information:

(A) Indicate specific diagnosis:

_____________________________________________________________________

(B) Indicate specific symptom (circle all that apply): cachexia severe pain severe nausea

seizures

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OFFICE USE ONLY – NOTES:

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_____________________________________________________________________________________________

State of Vermont Department of Public Safety

Marijuana Registry

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BON A FIDE HEALTH CARE PROFESSIONAL-PATIENT RELATIONSHIP STATEMENT

I HAVE a bona fide health care professional-patient relationship with the pa tie nt.

I do NOT have a bona fide health care professional-patient relationship with the patient, and the medical condition IS of

recent or sudden onset and the patient has not had a previous health care professional who is able to verify the nature of the

disease and it s symptoms.

I do NOT have a bona fide health care professional-patient relationship wit h the patient, and the medica l c ondition IS NOT of

recent or sudden onset and a previous health care professional was able to verify the nature of the disease and its symptoms.

ATTESTATION OF INFORMATION

I certify:

1) I am a health care professional;

A) licensed as a physician or ost e opathi c phys i ci an under 26 V.S.A Chapter 23 or Chapter 33;

B) licensed as a naturopathic physician under 26 V.S.A C hapter 81 , who has a special license endorsement authorizing the

individual to prescribe, dispense, and administer prescription medicines to the extent that a diagnosis provided by a

naturopath under this chapte r is within t he sco pe of his or he r pra c tic e ;

C) certified as a physician’s assistant under 26 V.S.A Chapter 31; or

D) licensed as a n advanced practice registered nurse under 26 V.S.A Chapter 28,

in good standing with the regulating state, a nd that the facts stated above are tr ue a nd accurate to the best of my knowledge and

belief.

2) Reasonable medical efforts have been made over a reasonable amount of time without success to relieve the patient’s

symptoms.

3) I understand, notwithstanding any law to the contrary, a person who knowingly provides false information on this application

may be guilty of perjury and imprisoned for not more than one year or fined not more than $1,000.00 or both. This penalty

shall be i n ad dition to a ny other penalties that may appl y.

This form is to verify the nature of the disease and its symptoms; this is not a prescription or medical recommendation for

the use of marijuana.

Health Care Professional’s Signature: _______________________________________ Date: _____________________

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

I hereby authorize the health care professional named on this form to release my protected medical information to the

Marijuana Registry to verify a nd confir m the accurac y of t h e infor mation co ntai ned within th is for m. I author ize the name d health

care professional to:

• Disclose the nature, symptoms, and duration of the medical condition identified on this form for the purpose of

deter mining that it meets the legal definition of a d e bilitating medical condit ion on page 1 of t h is fo rm;

• Disclose whether the named health care professional and I have a bona fide health care professional-patient relationship,

as defined by law and on page 1 of this form;

• Confirm the accuracy of the infor mation contained in this form.

I understand that any information released to the Registry will be used solely to confirm the accuracy of the information

contained in this form. While the information will no longer be covered by the HIPAA Privacy Rule, Vermont law

requires the

Registry to keep all infor mation confidential, except for the prosecution of false swearing. I understand this authorizati on is valid

for one year from the date the Registry receives this form, unless a written communication revoking this authorization or a new

authorization is received by the Registry. I understand that I have the right to revoke this authorization at any time by notifying

both the heal th care professional named on thi s form and to the Registry in wri ting.

Patient Applicant Signature REQUIRED: _______________________________________________ Date: ____________

If the patient applicant is under the age of 18 or has a court appointed guardia n the section below must be completed:

Parent or Guardian Signat ure : __________ ____ _____ _______________________________________ Date: ____________

THIS FORM MUST BE SUBMITTED WITH A PATIENT APPLICATION!