Fillable Printable Medical Marijuana Registry Application Form- Alaska
Fillable Printable Medical Marijuana Registry Application Form- Alaska
Medical Marijuana Registry Application Form- Alaska
MMRApplicantLetter
Departmentof
HealthandSocialServices
DIVISIONOFPUBLICHEALTH
BureauofVitalStatistics
P.O. Box 110699
Juneau, Alaska 99811-0699
Main: 907.465.5423
Fax: 907.465.3423
DearApplicant:
PerAlaskaStatute17.37.010regardingthemedicalusesofmarijuana,theenclosed
“ApplicationforMedicalMarijuanaRegistry”and“PhysicianStatement”mustbecompletedby
theapplicant.Further,ifaprimarycaregiverisspecified,theform“PrimaryCaregiver
ApplicationforMedicalMarijuanaRegistry”mustalsobecompleted.Iftheapplicantalso
specifiesanalternatecaregiver,theform“AlternateCaregiverApplicationforMedical
MarijuanaRegistry”mustbecompleted.
Anonrefundablefee(7AAC34.080(a))of$25.00($20.00forarenewal)andalegible
photocopyoftheAlaskaDriver’sLicenseorAlaskaIdentificationCardoftheapplicantandall
caregiversmustbesubmittedwiththeapplication.Renewalapplicationssubmittedaftera
registryidentificationcardhasexpiredwillbeconsideredanewapplicationandtheapplicant
willberequiredtopaythefeeforfirst‐timeapplicants.
Priortomailingyourapplication,reviewittobesurethatallrequiredinformationhasbeen
completed.Ifyourapplicationisnotcomplete,itwillbedeniedandyouwillnotbeallowedto
reapplyforaperiodofsixmonths.Pleasemakeyourcheckormoneyorderpayabletothe
BureauofVitalStatistics;checksmustbepreprintedwithyournameandaddress;andmailthe
checkalongwiththeapplicationtothefollowingaddress:
AlaskaBureauofVitalStatistics
MarijuanaRegistry
P.O.Box110699
Juneau,AK99811‐0699
Youmaywishtouse“ReturnReceiptService”formailingtobesurethatyourapplicationand
feesarereceivedbytheBureau.
Ifyouhave
anyquestionsorconcerns,pleasecontactthemarijuanaregistrysectionofthe
BureauofVitalStatisticsat(907)465‐5423.
MedicalMarijuanaRegistryApplicationInstructions
Pleasereadthefollowinginstructionscarefully.Ifyourapplicationisnotcomplete,itmaybe
denied.
Apatientapplyingforamedicalmarijuanaregistryidentificationcardmustprovidetothe
department:
1. Theoriginalcompletedcopyoftheattachedapplicationform(photocopieswillnotbe
accepted)thatincludesthefollowing:
Theapplicant'sname,mailingaddress,physicaladdress,dateofbirth,andAlaska
driver’slicensenumberorAlaskaidentificationcardnumber;
Thename,address,andtelephonenumberofthe patient'sphysician;
Thenameandaddressofthepatient'sprimarycaregiver,ifoneisdesignatedatthe
timeofapplication;and
Theapplicant'ssignature.
2. Iftheapplicantisaminor,anoriginalstatementinwriting(photocopieswillnotbe
accepted)bytheminor'sparentorlegalguardianresidinginAlaska,statingthatthe
parentorguardian:
Consentstoserveastheminor'sprimarycaregiver;and
Givestheparentorguardian'spermissionfortheminortoengageinthemedicaluse
ofmarijuana;
3. Theoriginal,signedformofthephysician’sstatement(photocopiesofthephysician’s
statementwillnotbeaccepted)statingthatthepatienthasbeendiagnosedwitha
qualifying
debilitatingmedicalconditionandtheconclusionofthepatient'sphysician
thatthepatientmightbenefitfromthemedicaluseofmarijuanaoracertifiedcopyof
thatdocumentation;and
4. Theapplicationfeeof$25fortheoriginalrequestor$20feeifitisforatimelyrenewal
(yourcurrentcardhasnotexpired).
5. Mailthisformwithamoneyorderoracheck.Checksmustbepreprintedwithyour
nameandaddress.Thereisa$30.00NSFfeeforreturnedchecks.Pleasemakechecks
payabletotheBureauofVitalStatistics.
1 Rev. 06/2013
Application for Medical Marijuana Registry
The appli cation fee is $25 for initial application; or $ 20 f or a renewal appl ic atio n (current card has not ex pir ed).
A photocopy of the Applic ant’s Alaska Driver’s License or Alaska Identificat ion Card must be included with the application.
A witness must be pr esent when the A pplica nt signs and dates the application. The witness must then si gn and d ate the application.
A statement fro m the Applic ant’s physician, u s ing either the physician’s st atement form (page 4) or a lett er addressing th e conditions
mentio ned in the physician’s statem ent form, sign ed by the Applica nt’s physician must be attached.
Mail this f orm with a money order or a check. Checks must be pre printed with your name and address. There is a $30.00 NSF fee for
returned checks. Please m ake checks payable to the Bureau of Vital Statistics.
Name:
(First Middle Last)
Mailing Address:
Physical Address:
City, State, Zip:
Phone:
Date of Birth (mm/dd/yyyy)
AK Driver’s License/AK ID Number:
If the Applicant is a minor (under the age of 18), please fill out this section:
I, , state that I am the parent or guardian of
(Name of parent or guardian) (Minor applicant’s name)
and that the minor’s physician has explained the possible risks and be nefits of medical use of marijuana to me an d that I consent to
serve as the primary caregiv er for the pati ent and to control the acquisition, possession, dosage, and frequency of use of marijuana by
the minor.
Parent or Guardian Sig nature: Date:
Note: The parent or guardian must also register as the applicant’s pri mary caregiver (page 2).
Physician’s Information:
Name:
(First Middle Last)
Mailing Address:
Physical Address:
City, State, Zip:
Phone:
Applicant’s Signature:
Date:
Witness’ Printed Name:
Witness’ Signature:
Date:
State Office use only:
Patient #:
Caregiver #: Issue Date: Expiration Date :
Mailto: AlaskaBureauofVitalStatistics
MedicalMarijuanaRegistry
POBox110699
Juneau,AK99811‐0699 PH:907‐465‐5423
InitialApplication
Renewal
2 Rev. 06/2013
Primary Caregiver Application for
Medical Marijuana Registry
Please note that a Primary Caregiver is not required for an Applicant to be approved for the Medical Marijuana Registry.
A photocopy of the Primary Caregiver’s Alaska Driver’s License or Alaska Identification Card must be included with this
application.
A witness must be present when the Primary Caregiver signs and dates the application. The witness must then sign and
date the application.
Name:
(First Middle Last)
Mailing Address:
Physical Address:
City, State, Zip:
Phone:
Date of Birth (mm/dd/yyyy)
AK Driver’s License/AK ID Number:
Check all that apply.
I am at least 21 years of age;
I have never been convicted of a felony offense under AS 11.71 or AS 11.73 or a law or ordinance of
another jurisdiction with elements similar to an offense under AS 11.71 or AS 11.73;
I am not currently on probation or parole from this or another jurisdiction.
I certify under penalty of perjury that the foregoing is true.
Primary Caregiver’s
Signature:
Date:
Witness’ Printed Name:
Witness’ Signature:
Date:
3 Rev. 06/2013
Alternate Caregiver Application for
Medical Marijuana Registry
Please note that an Alternate Caregiver is not required for an Applica n t to be approved for the Medical Marijuana Registry. This
form is compl eted if the Applicant wishes to have both a Primary Car egive r and an Altern ate Car egive r.
A photocopy of the Alternate Caregiver’s Alaska Driver’s License or Alaska Identification Card must be included with this
application.
A witness must be present when the Alternate Caregiver signs and dates the application. The witness must then sign
and date the application.
Name:
(First Middle Last)
Mailing Address:
Physical Address:
City, State, Zip:
Phone:
Date of Birth (mm/dd/yyyy)
AK Driver’s License/AK ID Number:
Check all that apply.
I am at least 21 years of age;
I have never been convicted of a felony offense under AS 11.71 or AS 11.73 or a law or ordinance of
another jurisdiction with elements similar to an offense under AS 11.71 or AS 11.73;
I am not currently on probation or parole from this or another jurisdiction.
I certify under penalty of perjury that the foregoing is true.
Alternate Caregiver’s
Signature:
Date:
Witness’ Printed Name:
Witness’ Signature:
Date:
4 Rev. 06/2013
Physician Statement for
Medical Marijuana Registry Application
I
, , state that I personally examined
(Physician’s Name) (Applicant’s Name)
on and that the examination took place in the context of a bona fide physician-patient relationship;
(Date of examination)
and that has a debilitating medical condition qualifying under AS 17.37.070.
(Applicant’s Name)
I have considered other approved medications and treatments that might provide relief, that are reasonably available to the
patient, and that can be tolerated by the patient, and have concluded that the patient might benefit from the medical use of
marijuana.
Physician’s Signature: Date:
Physician’s License Number: __________________________
The physician must either be licensed to practice medicine in the state of Alaska or must be an offic er in the regular medical
service of the armed forces of the United States or the United States Public Health Service while in the discharge of their
official duties, or while volunteering services without pay or other remuneration to a hospital, clinic, medical office, or other
medical facility in Alaska.
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Statutory Citations for Medical Marijuana Registry Application
Applicant:
AS 17.37.010(c) In order to be placed on the state's confidential registry for the medical use of
marijuana, an adult patient or a parent or guardian of a minor patient shall provide to the department
(1) a statement signed by the patient's physician
(A) stating that the physician personally examined the patient and that the examination took
place in the context of a bona fide physician-patient relationship and setting out the date
the examination occurred;
(B) stating that the patient has been diagnosed with a debilitating medical condition; and
(C) stating that the physician has considered other approved medications and treatments that
might provide relief, that are reasonably available to the patient, and that can be tolerated
by the patient, and that the physician has concluded that the patient might benefit from
the medical use of marijuana;
(2) a sworn application on a form provided by the department containing the following information:
(A) the name, address, date of birth, and Alaska driver's license or identification card
number of the patient;
(B) the name, address, and telephone number of the patient's physician; and
(C) the name, address, date of birth, and Alaska driver's license or identification card
number of the patient's primary caregiver and alternate caregiver if either is designated
at the time of application, along with the statements required under (d) of this section;
and
(3) if the patient is a minor, a statement by the minor's parent or guardian that the patient's
physician has explained the possible risks and benefits of medical use of marijuana and that
the parent or guardian consents to serve as the primary caregiver for the patient and to control
the acquisition, possession, dosage, and frequency of use of marijuana by the patient.
Caregiver:
AS 17.37.010(c) In order to be placed on the state's confidential registry for the medical use of
marijuana, an adult patient or a parent or guardian of a minor patient shall provide to the department
(2) a sworn application on a form provided by the department containing the following information:
(C) the name, address, date of birth, and Alaska driver's license or identification card
number of the patient's primary caregiver and alternate caregiver if either is designated
at the time of application, along with the statements required under (d) of this section;
and
AS 17.37.010(d) A person may be listed as the primary caregiver or alternate caregiver for a patient if
the person submits a sworn statement on a form provided by the department that the person
(1) is at least 21 years of age;
2
(2) has never been convicted of a felony offense under AS 11.71 or AS 11.73 or a law or
ordinance of another jurisdiction with elements similar to an offense under AS 11.71 or AS
11.73; and
(3) is not currently on probation or parole from this or another jurisdiction.
AS 17.37.010(e) A person may be a primary caregiver or alternate caregiver for only one patient at a
time unless the primary caregiver or alternate caregiver is simultaneously caring for two or more
patients who are related to the caregiver by at least the fourth degree of kinship by blood or marriage.
AS 17.37.010(q) A primary caregiver may only act as the primary caregiver for the patient when the
primary caregiver is in physical possession of the caregiver registry identification card. An alternate
caregiver may only act as the primary caregiver for the patient when the alternate caregiver is in
physical possession of the caregiver registry identification card.
Physician Information:
AS 17.37.010(c) In order to be placed on the state's confidential registry for the medical use of
marijuana, an adult patient or a parent or guardian of a minor patient shall provide to the department
(1) a statement signed by the patient's physician
(A) stating that the physician personally examined the patient and that the examination
took place in the context of a bona fide physician-patient relationship and setting out the
date the examination occurred;
(B) stating that the patient has been diagnosed with a debilitating medical condition; and
(C) stating that the physician has considered other approved medications and treatments
that might provide relief, that are reasonably available to the patient, and that can be
tolerated by the patient, and that the physician has concluded that the patient might
benefit from the medical use of marijuana;
(2) a sworn application on a form provided by the department containing the following information:
(B) the name, address, and telephone number of the patient's physician.
AS 17.37.010(r) The department may not register a patient under this section unless the statement of
the patient's physician discloses that the patient was personally examined by the physician within the
16-month period immediately preceding the patient's application. The department shall cancel,
suspend, revoke, or not renew the registration of a patient whose annual resubmission of updated
written documentation to the department under (k) of this section does not disclose that the patient was
personally examined by the patient's physician within the 16-month period immediately preceding the
date by which the patient is required to annually resubmit written documentation.
Debilitating Medical Condition:
AS17.37.070(4) “debilitating medical condition” means
(A) cancer, glaucoma, positive status for human immunodeficiency virus, or acquired
immune deficiency syndrome, or treatment for any of these conditions;
3
(B) any chronic or debilitating disease or treatment for such diseases, which produces, for a
specific patient, one or more of the following, and for which, in the professional opinion
of the patient’s physician, such condition or conditions reasonably may be alleviated by
the medical use of the marijuana: cachexia; severe pain; severe nausea; seizures,
including those that are characteristic of epilepsy; or persistent muscle spasms,
including those that are characteristic or multiple sclerosis; or
(C) any other medical condition, or treatment for such condition, approved by the
department, under regulations adopted under AS17.37.060 or approval of a petition
submitted under AS17.37.060.
Other:
AS 17.37.010(i) A person may not apply for a registry identification card more than once every six
months.
AS 17.37.010(k) When there has been a change in the name, address, or physician of a patient who
has qualified for a registry identification card, or a change in the name or address of the patient's
primary caregiver or alternate caregiver, that patient must notify the department of the change within 10
days. To maintain an effective registry identification card, a patient must annually resubmit updated
written documentation, including a statement signed by the patient's physician containing the
information required to be submitted under (c)(1) of this section, to the department, as well as the name
and address of the patient's primary caregiver or alternate caregiver, if any.
AS 17.37.010(l) A patient who no longer has a debilitating medical condition and the patient's primary
caregiver, if any, shall return all registry identification cards to the department within 24 hours of
receiving the diagnosis by the patient's physician.
AS 17.37.010(m) A copy of a registry identification card is not valid. A registry identification card is not
valid if the card has been altered, mutilated in a way that impairs its legibility, or laminated.
AS 17.37.010(n) The department may revoke a patient's registration if the department determines that
the patient has violated a provision of this chapter or AS 11.71.
