Illinois Medical Cannabis Patient Program
Health Care Professional Written Certification Form
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)