Illinois Medical Cannabis Patient Program
Application for a Designated Caregiver Registry Identification Card
REQUIRED DOCUMENTS
Place the following items in an envelope or upload in the electronic application:
❑
Non-refundable application fee (Check or Money Order to Illinois Department of Public Health)
❑
Photograph
• Taken in the last 30 days
• Taken against a plain, white or off-white background or backdrop
• In natural color (Do not use a filter)
• Full-face view directly facing the camera with a neutral facial expression and both eyes open
• At least 2 inches by 2 inches in size
It is recommended you use a passport photo vendor to ensure the photograph meets these requirements.
Contact the Division of Medical Cannabis if a photograph is in violation of or contradictory to the qualifying patient’s religious
convictions.
❑
Proof of age and identity
Submit a clear, color copy of an Illinois Driver’s License, Illinois State ID, or the photograph page of a US passport.
❑
Proof of residency
If your Driver’s License, Temporary Visitor Driver's License or State ID address matches your application submit one additional
proof of residency. If you submit a US Passport as your proof of identity or your Driver’s License or State ID address does not
match the address on your application, submit two of the following:
• Pay stub or electronic deposit receipt, issued less than 60 days prior to the application date, that shows evidence of
withholding for State income tax
• Valid voter registration card with an address in Illinois
• Bank statement (dated less than 90 days prior to application) or credit card statement (dated less than 60 days prior to
application);
• Deed/title, mortgage or rental/lease agreement; property tax bill;
• Insurance policy (current coverage for automobile, homeowner's, health or medical, or renter's);
• Medical claim or statement of benefits (from a hospital or health clinic, private insurance company or public (government)
agency, dated less than 12 months prior to application)
• Tuition invoice/official mail from college or university, dated less than the 12 months prior to application
• Utility bill, including, but not limited to, those for electric, water, refuse, telephone land-line, cellular phone, cable or gas,
issued less than 60 days prior to application
• W-2 from the most recent tax year
Proof of residency must include name and address and match the address on the application
Mail the application and required documents to:
Illinois Department of Public Health
Division of Medical Cannabis
535 West Jefferson Street
Springfield, Illinois 62761-0001
Questions? Contact the Division of Medical Cannabis at 855-636-3688 or
DPH.MedicalCannabis@Illinois.gov.
