Fillable Health Care Professional Written Certification Form ***Do not

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Health Care Professional Written Certification Form ***Do not

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State of Illinois
Illinois Department of Public Health
Page 1 of 3
Printed by Authority of the State of Illinois
12/19
Illinois Medical Cannabis Patient Program
Health Care Professional Written Certification Form
***Do not use this form for Terminal Illness***
INSTRUCTIONS
Type or print clearly and answer all of the questions. This certification does not constitute a prescription
for medical cannabis.
HEALTH CARE PROFESSIONAL - GIVE THE COMPLETED and SIGNED FORM TO THE PATIENT
This FORM must be included with the qualifying patient application.
The qualifying patient shall scan form in .PDF format and upload with application documents on-line
https://medicalcannabispatients.illinois.gov or mail WITH application to: Illinois Department of Public Health,
Division of Medical Cannabis
The health care professional written certification form is required for all qualifying patients, including those
under 18 years of age, EXCEPT for terminally ill patients and qualifying patients who are veterans receiving
treatment for a debilitating condition at a medical facility operated by the U.S. Veteran’s Administration (VA).
QUALIFYING PATIENT INFORMATION
HEALTH CARE PROFESSIONAL INFORMATION ON FILE WITH THE ILLINOIS DEPARTMENT OF
FINANCIAL AND PROFESSIONAL REGULATION
First Name Middle Name Last Name
Home Address
Apartment or Suite # City State
IL
ZIP Code
Date of Birth (mm/dd/yyyy) Gender
❑ Male ❑ Female
First Name Middle Name Last Name
Office Address (Location where the Qualifying Patient’s Medical Examination was conducted)
Suite # City State
IL
ZIP Code
Office Telephone Number (###-###-####) E-mail Address
Illinois License Number Illinois Controlled Substances License Number
Length of time patient has been under your care (years/months) Date of in-person medical examination relating to this certification
(mm/dd/yyyy)
IOCI 20-446
State of Illinois
Illinois Department of Public Health
Page 2 of 3
Printed by Authority of the State of Illinois
12/19
Illinois Medical Cannabis Patient Program
Health Care Professional Written Certification Form
***Do not use this form for Terminal Illness***
DEBILITATING MEDICAL CONDITION
The qualifying patient is diagnosed with and is currently undergoing treatment for the following debilitating
medical condition(s) (check all that apply).
❑ agitation of
Alzheimer's disease
❑ acquired immune
deficiency syndrome
(AIDS)
❑ amyotrophic lateral
sclerosis (ALS)
❑ anorexia nervosa
❑ Arnold-Chiari
malformation
❑ autism
❑ cancer
❑ Causalgia
❑ chronic inflammatory
demyelinating
polyneuropathy
❑ chronic pain
❑ Crohn's disease
❑ CRPS (complex
regional pain
syndromes Type II)
❑ dystonia
❑ Ehlers-Danlos
syndrome (EDS)
❑ fibrous dysplasia
❑ glaucoma
❑ hepatitis C
❑ hydrocephalus
❑ hydromyelia
❑ interstitial cystitis
❑ irritable bowel
syndrome
❑ lupus
❑ migraines
❑ multiple sclerosis
❑ muscular dystrophy
❑ myasthenia gravis
❑ myoclonus
❑ nail-patella syndrome
❑ Neuro-Behcet’s
autoimmune disease
❑ neuropathy
❑ neurofibromatosis
❑ osteoarthritis
❑ Parkinson's disease
❑ polycystic kidney
disease (PKD)
❑ positive status
for human
immunodeficiency
virus (HIV)
❑ Post-Traumatic
Stress Disorder
(PTSD)
❑ reflex sympathetic
dystrophy (RSD)
complex regional pain
syndromes Type I
❑ residual limb pain
❑ rheumatoid
arthritis (RA)
❑ seizures (including
those characteristic
of Epilepsy)
❑ severe fibromyalgia
❑ Sjogren's syndrome
❑ spinal cord disease:
including but not
limited to arachnoiditis
❑ spinal cord injury -
damage to the nervous
tissue of the spinal
cord with objective
neurological indication
of intractable spasticity.
❑ spinocerebellar
ataxia (SCA)
❑ superior canal
dehiscence syndrome
❑ Syringomyelia
❑ Tarlov cysts
❑ Tourette’s syndrome
❑ traumatic brain injury
(TBI) and post-
concussion syndrome
❑ ulcerative colitis
❑ cachexia/wasting
syndrome
Indicate the underlying
chronic or debilitation
condition
IOCI 20-446
Illinois Medical Cannabis Patient Program
Health Care Professional Written Certification Form
ATTESTATIONS
I _____________________________________________ (the health care professional), have made or
confirmed a diagnosis of a debilitating medical condition, as defined in the Compassionate Use of Medical
Cannabis Program Act, for the qualifying patient and by my signature below certify the following:
1. I have established a bona-fide relationship with the qualifying patient applicant. The qualifying patient is
under my care, either for his/her primary care or for his/her debilitating medical condition, as specified
on this form. This bona-fide relationship is not limited to the preparation of a written certification for the
patient to use medical cannabis or a consultation simply for that purpose.
2. I have conducted an in-person physical examination of the qualifying patient within the last 90 calendar
days. I completed an assessment of the qualifying patient’s current medical condition, including symptoms,
signs and diagnostic testing, related to the debilitating medical condition I diagnosed or confirmed. I
understand the Illinois Department of Public Health may request additional confirmation of the
assessment(s) performed for this qualifying patient’s debilitating medical conditions.
3. I have completed an assessment of the qualifying patient’s medical history, including the review of medical
records from other treating health care professionals from the previous 12 months. I have established a
medical record for the qualifying patient related to the patient’s debilitating condition and continued
treatment for the condition(s) under my care.
I _____________________________________________ (the health care professional), hereby certify I am
duly licensed to practice medicine in the state of Illinois. The qualifying patient has the debilitating medical
condition(s) specified, and the patient is under my treatment or management for the debilitating condition(s)
and/or their primary care. I attest the information provided in this written certification is true and correct.
This recommendation does not constitute a prescription for medical cannabis.
_____________________________________________________________ ____________________________
Health Care Professional signature (no stamps accepted) Date of signature (mm/dd/yyyy)
State of Illinois
Illinois Department of Public Health
Page 3 of 3
Printed by Authority of the State of Illinois
12/19
IOCI 20-446
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Completed 22 November 2020

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