Fillable Printable Medical Marijuana Registry Application Form - Colorado
Fillable Printable Medical Marijuana Registry Application Form - Colorado
Medical Marijuana Registry Application Form - Colorado
Medical Marijuana Registry
4300 Cherry Creek Drive South, Denver, CO 80246-1530 303-692-2184
E-mail: medical.marijuana@state.co.us Website: www.cdphe.state.co.us/hs/medicalmarijuana
MMR1001 – Adult Application – Revised December 2011 Page 1 of 8
Application Instructions
Colorado Medical Marijuana Registration Cards are available only for Colorado residents being treated for an active, debilitating
medical condition. To apply for a registration card, please submit a complete, accurate application packet as described below. If
your application is incomplete or incorrect, the entire packet will be returned to you. If you make a mistake on a form, please
complete a new form. Do not write over, white-out or cross-out information. This will void the form.
A complete application packet includes:
1. An Application for Registration Card completed by you, signed and notarized.
2. A Physician Certification completed by your doctor.
3. A copy of your Colorado ID. If you do not have a Colorado ID, submit proof of identity and Colorado residency.
4. A copy of your caregiver’s valid ID, if a caregiver is selected.
5. A form of payment or a Request for Fee Waiver/Tax Exempt Status form and supporting materials.
1. Medical Marijuana Registry Application
a. Please complete the entire application. Write or type clearly and neatly.
b. You may select to have a caregiver or a Medical Marijuana Center. It is not required to have either.
c. If you are under age 18 or homebound, you may choose both a caregiver and a Medical Marijuana Center.
d. Complete the physician information. Make sure the physician information on the Medical Marijuana Registry
Application matches the information provided by your doctor on the Physician Certification.
e. You must sign and date this form in front of a Colorado notary. The date of your signature and the notary’s signature
must be the same.
f. The form cannot be notarized by the patient, the caregiver, the physician or the person who signs the payment.
2. Physician Certification
a. Your physician must complete and sign the Physician Certification.
b. The signing physician must be an MD or DO with an active Colorado medical license. Physicians with conditions or
restrictions on their licenses, or out-of-state licenses, are not accepted.
c. Send in your application packet as soon as possible after the physician signs the Physician Certification. The Registry
must receive your complete, correct application packet within 60 days of the physician’s signature. Application packets
with Physician Certifications more than 60 days old are rejected.
3. Proof of Identity and Residency
a. Medical Marijuana Registration cards are available only to Colorado residents. You must provide proof of your identity
and residency. Damaged, expired or tampered IDs are not valid.
b. If you select a caregiver, include a copy of the caregiver’s photo ID with the application packet.
PROOF OF IDENTITY AND COLORADO RESIDENCY
One (1) of the following:
Colorado Driver’s License
Colorado ID
Temporary Colorado Driver’s License
Temporary Colorado ID
Or two (2) of the following:
Minimum of one (1) from the group of IDs below -
Out of State Driver’s License
Out of State ID
Passport, Military ID (copy of front and back), Tribal ID
And a minimum of one (1) from the group below -
Proof of Colorado Employment (paycheck stub/W-2)
Copy of a utility, medical, or cable bill. (The mailing address on all
bills must match address on application. For utility and cable bills, the
service address must be in Colorado.)
i. All documents must be currently valid when received at the Registry. Damaged, expired, or tampered IDs are not valid.
ii. Proof of residency materials must be current, within 60 days of the date the Registry receives your paperwork.
iii. At least one (1) of these documents must show the patient’s date of birth
Application Instructions
MMR1001 – Adult Application – Revised December 2011 Page 2 of 8
4. Non-refundable $35 application fee or Request for Fee Waiver:
The following application fee and fee waiver processes are effective for applications received January 1, 2012 or later.
a. To pay $35 application fee: Make check or money order payable to CDPHE. We do not accept temporary checks.
Please write the patient’s name on the payment. Make sure the form of payment is signed. The notary cannot sign the
form of payment. The date of payment must be less than one (1) year old when received at the Registry.
b. To request fee waiver: You must submit a Fee Waiver Request (form #MMR1010) with your application packet. You
may qualify for a fee waiver if your household income is at 185% of the Federal Poverty Level or less. The chart below
indicates the annual household incomes, adjusted for family size, that qualify for a fee waiver.
Household incomes at 185% of 2011 Federal Poverty Guidelines*
Source: Federal Register, Vol. 76, No. 13, January 20, 2011, pp. 3637-3638
* Poverty guidelines are updated periodically in the Federal Register by the U.S. Department of Health and Human
Services under the authority of 42 U.S.C. 9902(2)
5. Application packets must be sent separately. Only one application packet and check/money order per envelope. If sending
by certified mail, certify each envelope separately.
6. Submit all items by mail or deliver to the Registry’s drop-box. The Registry does not accept forms by fax or e-mail.
Mail To:
Colorado Dept. of Public Health & Environment
HSV-MMR
4300 Cherry Creek Drive South
Denver, CO 80246-1530
Drop-Box:
Colorado Dept. of Public Health & Environment
710 S. Ash Street, Southeast Entrance
Open: Monday-Friday, 7:00 a.m. to 6:00 p.m.
The drop box is on the wall inside the first set of glass doors. Your
paperwork must be in a sealed envelope. You will not receive a
receipt. If you wish to have a receipt, please mail in your
paperwork by certified mail.
For more information, please visit: www.cdphe.state.co.us/hs/medicalmarijuana.
The Registry is not affiliated with any privately operated club, organization, or dispensary.
# in Family
Annual Income
1
$ 20,146.50
2
$ 27,213.50
3
$ 34,280.50
4
$ 41,347.50
5
$ 48,414.50
6
$ 55,481.50
7
$ 62,548.50
8
$ 69,615.50
Each additional
$ 7,067.00
Application Instructions
MMR1001 – Adult Application – Revised December 2011 Page 3 of 8
Application Packet Checklist:
The Application is complete and accurate.
The Application was signed and dated by you and a Colorado notary.
The dates of your signature and the notary’s signature match.
The Physician Certification is complete and accurate.
The date of the Physician’s signature is current. Mail your application packet as soon as possible after
your physician signs the Physician Certification.
There are no areas on any of the forms where information has been written over, crossed out or white-out
was used.
You have included a clear copy of your valid Colorado ID.
If you do not have a Colorado ID, you have included a clear copy of your ID and proof of residency.
If included, the address on your proof of residency paperwork matches the address on the Application.
If included, all copies of utility or cable bills show both the “mail to” address and the “service” address.
Both addresses are in Colorado.
You have made copies of all the documents you are sending to the Registry.
You have included a form of payment or the Request for Fee Waiver/Tax-Exempt Status form.
Submit your application packet for yourself. Do not allow anyone else to submit the paperwork for you.
Send your application packet by certified mail to have proof of submission. Keep the mail receipt.
Check our website (www.cdphe.state.co.us/hs/medicalmarijuana) for a time estimate for processing
applications.
Questions can be sent by e-mail to medical.marijua[email protected]s or by phone at 303-692-2184.
Application Review Process:
1. Initial Review: The Registry reviews all applications against criteria described in the Application Instructions.
The nonrefundable application fee, if included in the application packet, is cashed.
2. Approved Application: If an application packet is complete and has all supporting materials, a card is mailed to
the patient.
3. Rejected Application: If an application packet is inaccurate or incomplete, the Registry returns the entire
application packet to the patient. A rejection letter is sent with the application packet detailing corrections that are
needed. With each rejection, patients are given 60 days to make corrections without paying additional application
fees. Patients are given two (2) opportunities to re-submit their application packet with corrections to the Registry.
4. Approved Corrections: When a corrected application packet is returned, it is again reviewed for accuracy and
completeness. If the application packet is correct, a card is mailed to the patient.
5. Corrections Beyond 60-Days: Patients who do not submit corrections within the 60-day window must submit a
new application packet and an additional $35 application fee.
6. Denial: The application is denied after the patient has submitted inaccurate or incomplete application information
three times (the original application plus two correction attempts). The patient will have to wait six (6) months
before re-applying for a Medical Marijuana Registration card, if the application is denied.
7. Appeals: If an application is denied, or the Registry suspends or revokes the patient’s current registration card, a
notice will be sent to the patient with details regarding the reason for denial, suspension or revocation. If the
patient disagrees with a final decision from the Registry, the patient may send a letter to the Registry requesting
an appeals hearing. The request for hearing must be received by the Registry within thirty (30) calendar days
from the date of the postmark on the notice.
Medical Marijuana Registry
4300 Cherry Creek Drive South, Denver, CO 80246-1530 303-692-2184
E-mail: medical.marijuana@state.co.us Website: www.cdphe.state.co.us/hs/medicalmarijuana
MMR1001 – Adult Application – Revised December 2011 Page 4 of 8
Application for Registration Card
New: This is the first time I have applied in Colorado. Renewal: I have been on the Colorado Registry before.
Section A: Patient Information (Required)
The name on the form must match the legal name on your photo ID.
1. Social Security Number
- -
2. Last Name
3. First Name
4. Middle Initial
5. Mailing Address (including Apartment or Suite #)
6. City
State
CO
7. Zip Code
8. County
9. Date of Birth
/ /
10. Telephone Number
( ) -
11. E-mail Address (optional)*
12. Gender
Male Female
* By providing your e-mail address, you agree to receive communication from the Registry by e-mail.
Section B: Caregiver Information (Optional)
A copy of the caregiver’s photo ID is required. The name on the form must match the legal name on the caregiver’s ID.
Only homebound patients, or patients under age 18, may list both a caregiver and a Medical Marijuana Center.
13. Caregiver’s Last Name (as on ID)
14. Caregiver’s First Name (as on ID)
15. Middle Initial
16. Caregiver’s Mailing Address (including Apartment or Suite #)
17. City
18. State
19. Zip Code
20. Date of Birth
/ /
21. Telephone Number
( ) -
Section C: Medical Marijuana Center Information (Optional)
Only homebound patients, or patients under age 18, may list both a caregiver and a Medical Marijuana Center.
22. Name of Medical Marijuana Center
23. Mailing Address of the Medical Marijuana Center
24. City
State
CO
25. Zip Code
26. Telephone Number
( ) -
Section D: Physician Information (Required)
Physician name must match the name on the Physician Certification submitted with this application packet.
27. Physician’s Last Name
28. Physician’s First Name
I hereby certify that the above information is correct and complete.
29. Patient’s Signature:
30. Date Signed: (mm/dd/yyyy)
The signature and proof of identity of the above individual was subscribed and sworn to before me by
_____________________________________________ in _______________________ County, Colorado on this
(Name of patient printed by notary) (County name)
_________day of _____________, 20____.
(Day) (Month)
___________________________________
(Notary’s official signature)
___________________________________
(Commission expiration date) AFFIX NOTARY SEAL
STAFF
ONLY
Homebound
Yes No
Tax Exempt
Yes No
EPU
Approval
Yes No
QA Approval
IU Approval/
Card Printed
Yes No
Corrections:
Physician Certification Instructions
MMR1001 – Adult Application – Revised December 2011 Page 5 of 8
1. Complete the entire form, sign and date.
2. If you make a mistake on this form, please complete a new form. Do not write over, white-out or
cross-out information. This will void the form.
3. Please keep a copy of the form in the patient’s medical record. To avoid fraud, the Registry verifies all physician
signatures. You will receive a verification letter for patients in the months the Registry receives Physician
Certifications with your signature.
4. Please do not fax or e-mail the form to the Registry. The patient must submit the Physician Certification along
with his or her complete Medical Marijuana Registry application packet.
5. This does not constitute a prescription for marijuana.
6. To sign the form, you must be an MD or DO with an active Colorado medical license. Physicians with condition
or restrictions on their licenses, or out-of-state licenses, are not accepted.
7. A copy of your current DEA certification must be on file in the Registry’s office. If you have not already provided
this, please fax a copy to 303-758-5182. If your DEA is not on file when we receive your patient’s paperwork, it
will be rejected.
8. Encourage patients to submit their application packets as soon as possible after you sign the Physician
Certification. The Registry rejects Physician Certifications that are more than 60 days old.
9. The Registry has included in the application packet, for your review, “Regulation 8: Physician requirements;
reasonable cause for referrals of physicians to the Colorado Medical Board; reasonable cause for
department adverse action concerning physicians; appeal rights.” For a link to the complete Board of Health
rules, please visit our website www.cdphe.state.co.us/hs/medicalmarijuana.
10. You may contact the Registry at medical.marijuana@state.co.us or (303) 692-2184, if you have any questions.
Medical Marijuana Registry
4300 Cherry Creek Drive South, Denver, CO 80246-1530 303-692-2184
E-mail: medical.marijuana@state.co.us Website: www.cdphe.state.co.us/hs/medicalmarijuana
MMR1001 – Adult Application – Revised December 2011 Page 6 of 8
Physician Certification
Patient Information
1. Last Name (as on ID)
2. First Name (as on ID)
3. Middle Initial
4. Date of Birth
/ /
5. What is the date of physical examination for the purpose of the medical marijuana recommendation?
(mm/dd/yyyy) / /
6. How many times during the previous 12 months have you seen this patient?
7. Are you available to provide follow-up care for this patient? Yes No
8. What is the date by which the patient should schedule a follow-up care visit? (mm/dd/yyyy) / /
9. In your opinion, is this patient homebound? Yes No
Physician Information
10. License Number
DR -
11. Last Name
12. First Name
13. Middle Initial
14. Mailing Address
15. City
16. State
17. Zip Code
18. Telephone Number
( ) -
19. Fax Number
( ) -
20. E-mail Address (optional)
21. DEA Certification: The Registry requires a copy of your current DEA certification for their files. If you have
not already provided this, FAX a copy to 303-758-5182 to prevent delays in processing this application.
Physician’s Statement
22. The above-named patient has been diagnosed with and is currently undergoing treatment for the following
chronic, debilitating medical condition.
a. Cancer b. Glaucoma c. HIV or AIDS positive
or The patient has a chronic or debilitating disease or medical condition that produces one or more of the
following and which, in the physician’s professional opinion, may be alleviated by the medical use of marijuana.
d. Cachexia e. Severe nausea f. Seizures g. Persistent muscle spasms
h. Severe pain (The etiology is required by law whenever severe pain is selected.)
Etiology: or Etiology unknown.
23. Please indicate the number of plants and ounces of marijuana you recommend for this patient.
Standard Amount: 6 plants/2 ounces
Increased Amount: plants/ ounces
24. Comments: (If no comments, the Registry recommends crossing through this area to prevent comments after your
signature.)
I hereby certify that I am a physician duly licensed in good standing to practice medicine in Colorado, and that I have a bona
fide physician-patient relationship with the above-named patient. I have assessed this patient’s medical history and current
medical condition. I conclude that this patient may benefit from the medical use of marijuana. This assessment is not a
prescription for the use of marijuana.
25. Physician’s Signature:
26. Date Signed (mm/dd/yyyy)
STAFF
ONLY
EPU
Approval
Yes No
Corrections:
Board of Health Rules: Regulation 8
MMR1001 – Adult Application – Revised December 2011 Page 7 of 8
Regulation 8: Physician requirements; reasonable cause for referrals of physicians to the Colorado Medical Board;
reasonable cause for department adverse action concerning physicians; appeal rights
A. Physician requirements. A physician who certifies a debilitating medical condition for an applicant to the medical
marijuana program shall comply with all of the following requirements:
1. Colorado license to practice medicine. The physician shall have a valid, unrestricted Colorado license to practice
medicine, which license is in good standing.
a. For the purposes of certifying a debilitating medical condition of an applicant and recommending the use of
medical marijuana for the medical marijuana program, "in good standing" means:
i. The physician holds a doctor of medicine or doctor of osteopathic medicine degree from an accredited
medical school;
ii. The physician holds a valid license to practice medicine in Colorado that is not restricted or conditioned,
unless the physician has received written confirmation from the Colorado medical board that the
physician’s scope of practice does not preclude recommending medical marijuana; and
iii. The physician has a valid and unrestricted United States Department of Justice federal drug enforcement
administration controlled substances registration.
2. Bona fide physician patient relationship. A physician who meets the requirements in subsection A.1 of this
Regulation 8 and who has a bona fide physician-patient relationship with a particular patient may certify to the state
health agency that the patient has a debilitating medical condition and that the patient may benefit from the use of
medical marijuana. If the physician certifies that the patient would benefit from the use of medical marijuana based
on a chronic or debilitating disease or medical condition, the physician shall specify the chronic or debilitating
disease or medical condition and, if known, the cause or source of the chronic or debilitating disease or medical
condition.
a. "Bona fide physician-patient relationship", for purposes of the medical marijuana program, means:
i. A physician and a patient have a treatment or counseling relationship, in the course of which the physician
has completed a full assessment of the patient's medical history and current medical condition, including an
appropriate personal physical examination;
ii. The physician has consulted with the patient with respect to the patient's debilitating medical condition
before the patient applies for a registry identification card; and
iii. The physician is available to or offers to provide follow-up care and treatment to the patient, including but
not limited to patient examinations, to determine the efficacy of the use of medical marijuana as a treatment
of the patient's debilitating medical condition.
b. A physician making medical marijuana recommendations shall comply with generally accepted standards of
medical practice, the provisions of the medical practice act, § 12-36-101 et seq. , C.R.S, and all Colorado
Medical Board rules.
c. The "appropriate personal physical examination" required by paragraph A.2.a.i of this Regulation 8 may not be
performed by remote means, including telemedicine.
3. Medical records. The physician shall maintain a record-keeping system for all patients for whom the physician has
recommended the medical use of marijuana. Pursuant to an investigation initiated by the Colorado medical board,
the physician shall produce such medical records to the Colorado Medical Board after redacting any patient or
primary caregiver identifying information.
4. Financial prohibitions. A physician shall not:
a. Accept, solicit, or offer any form of pecuniary remuneration from or to a primary caregiver, distributor, or any
other provider of medical marijuana;
b. Offer a discount or any other thing of value to a patient who uses or agrees to use a particular primary caregiver,
distributor, or other provider of medical marijuana to procure medical marijuana;
Board of Health Rules: Regulation 8
MMR1001 – Adult Application – Revised December 2011 Page 8 of 8
c. Examine a patient for purposes of diagnosing a debilitating medical condition at a location where medical
marijuana is sold or distributed; or
d. Hold an economic interest in an enterprise that provides or distributes medical marijuana if the physician
certifies the debilitating medical condition of a patient for participation in the medical marijuana program.
B. Reasonable cause for referral of a physician to the Colorado Medical Board. For reasonable cause, the department
may refer a physician who has certified a debilitating medical condition of an applicant to the medical marijuana registry
to the Colorado Medical Board for potential violations of sub-paragraphs 1, 2, and 3 of paragraph A of this rule.
C. Reasonable cause for department sanctions concerning physicians. For reasonable cause, the department may
sanction a physician who certifies a debilitating medical condition for an applicant to the medical marijuana registry for
violations of paragraph A.4 of this rule. Reasonable cause shall include, but not be limited to:
1. The physician is housed onsite and/or conducts patient evaluations for purposes of the medical marijuana program at
a location where medical marijuana is sold or distributed, such as a medical marijuana center, optional grow site,
medically infused products manufacturer, by a primary caregiver, or other distributor of medical marijuana.
2. A physician who holds an economic interest in an entity that provides or distributes medical marijuana, such as a
medical marijuana center, an infused products manufacturer, an optional grow site, a primary caregiver, or other
distributor of medical marijuana.
3. The physician accepts, offers or solicits any form of pecuniary remuneration from or to a primary caregiver, medical
marijuana center, optional grow site, medically infused product manufacturer, or any other distributor of medical
marijuana.
4. The physician offers a discount or any other thing of value, including but not limited to a coupon for reduced-price
medical marijuana or a reduced fee for physician services, to a patient who agrees to use a particular medical
marijuana center, primary caregiver, or other distributor of medical marijuana.
D. Sanctions. For reasonable cause, the department may propose any of the following sanctions against a physician:
1. Revocation of the physician’s ability to certify a debilitating medical condition and recommend medical marijuana
for an applicant to the medical marijuana registry; or
2. Summary suspension of the physician’s ability to certify a debilitating medical condition or recommend medical
marijuana for an applicant to the medical marijuana registry when the department reasonably and objectively
believes that a physician has deliberately and willfully violated section 14 of article xviii of the state constitution or
§ 25-1.5-106, C.R.S. and the public health, safety and welfare imperatively requires emergency action.
E. Appeals. If the department proposes to sanction a physician pursuant to paragraph c of this rule, the department shall
provide the physician with notice of the grounds for the sanction and shall inform the physician of the physician’s right
to request a hearing.
1. A request for hearing shall be submitted to the department in writing within thirty (30) calendar days from the date
of the postmark on the notice.
2. If a hearing is requested, the physician shall file an answer within thirty (30) calendar days from the date of the
postmark on the notice.
3. If a request for a hearing is made, the hearing shall be conducted in accordance with the state administrative
procedures act, § 24-4-101 et seq. , C.R.S.
4. If the physician does not request a hearing in writing within thirty (30) calendar days from the date of the notice, the
physician is deemed to have waived the opportunity for a hearing.
