Fillable PATIENT REGISTRATION PACKET (Vermont)

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PATIENT REGISTRATION PACKET (Vermont)

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The PATIENT REGISTRATION PACKET (Vermont) form is 18 pages long and contains:

  • 7 signatures
  • 41 check-boxes
  • 137 other fields

Country of origin: US
File type: PDF

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___________________________________________________________________________________________________________________________________
State of Vermont
Department of Public Safety
Marijuana Registry
[phone] 802-241-5115
45 State Drive
[fax] 802-241-5230
Waterbury, Vermont 05671-1300
[email]
DPS.MJRegistry@vermont.gov
www.medicalmarijuana.vermont.gov

PATIENT REGISTRATION PACKET
(Includes Patient application, Caregiver application, Health Care Professional Verification Form, and
Mental Health Care Provider Form)
APPLICATION CHECK SHEET
Instructions:
Carefully review the appropriate check list below prior to submitting your application to the VMR,
incomplete applications will be returned for completion and may delay processing. The VMR will process complete
applications within 30 days from receipt.
INITIAL APPLICANTS
1) Have you completed pages 1-3?
2) Have you submitted a photo following the instructions on page 3?
3) If you selected to “Cultivate” on page 1, did you provide the cultivation address and location within building?
4) Have you initialed all the Acknowledgements on page 2?
5) Have you enclosed a completed Health Care Professional Verification Form?
6) Have you enclosed a check or money order for the appropriate non-refundable fee payable to the Department of
Public Safety?
(Fees: $50 to register as a patient and a $50 fee to register a caregiver. Minors applying as a patient
may have 2 caregivers and the fee is waived for a parent/guardian applying as a caregiver.)
7) Verify the check or money order has been signed, dated, and the correct amount written out.
8) If designating a caregiver, has the person applying to be a caregiver completed pages 4-6?
RENEWAL APPLICANTS
Note:
1) Have you completed pages 1-3?
2) If you selected to “Cultivate” on page 1, did you provide the cultivation address and location within building?
3) Have you initialed all the Acknowledgements on page 2?
4) Have you enclosed a completed Health Care Professional Verification Form?
5) Have you enclosed a check or money order for the appropriate non-refundable fee payable to the Department of
Public Safety? (Fees: $50 Patient application and $50 for each Caregiver application)
6) Verify the check or money order has been signed, dated, and the correct amount written out.
7) If designating a caregiver, has the person applying to be a caregiver completed pages 4-6?
MAIL COMPLETED APPLICATIONS TO:
Department of Public Safety
Marijuana Registry
45 State Drive
Waterbury, VT 05671-1300
_____________________________________________________________________________________________
State of Vermont
[phone] 802-241-5115
Department of Public Safety
Marijuana Registry
[fax] 802-241-5230
[email] DPS.MJRegistry@vermont.gov
Page 1
(Revised 08/2018)
__________________________________________________________________________________________________________________________________________________________________
PATIENT REGISTRATION PACKET
Includes Patient application, Caregiver application, Health Care Professional Verification Form, & Mental Health Care Provider Form
Instructions: Carefully review all pages. Clearly complete ALL sections, unless labeled optional. Incomplete applications
will be returned for completion. All patient applications must be submitted with a non-refundable $50 check or money order
made payable to the Department of Public Safety.
1.) **PATIENT INFORMATION**
Application Type
(check one)
:
Initial Application Renewal Application
(ID #: __________________ Exp. Date: __________)
Full Legal Name: Last _______________________________ First _________________________________ M.I. ________
Mailing Address: _____________________________________________________________________________________
City, State, Zip: ______________________________________________________________________________________
Physical Address
(if different than mailing): _________________________________________________________________
City, State, Zip: __________________________________________ Telephone Number: ___________________________
E-mail address (OPTIONAL): __________________________________________________________________________
Gender (circle one): MA
LE FEMALE Eye Color: _____________ Weight: ________lbs. Height: ___ ft. _____ in.
Date of Birth: ____________ *VALID* VERMONT Driver’s License or Non-Driver ID #: ___________________________
2.) **DISPENSARY DESIGNATION** (Select only ONE dispensary. If more than one location is listed for below for a
dispensary appointment may be scheduled at either location.)
Champlain Valley Dispensary
(Burlington & South Burlington)
Grassroots Vermont
(Brandon)
PhytoCare Vermont
(Bennington)
Southern Vermont Wellness
(Brattleboro & Middlebury)
Vermont Patients Alliance
(Montpelier)
3.) **DISPENSARY COMMUNICATION & DELIVERY** (Dispensa
ries are REQUIRED to maintain ALL patient and
caregiver information as confidential in conformity with HIPAA. This authorization may be withdrawn at any time.)
May the Vermont Marijuana Registry (VMR) provide your address, phone
number, and email (if applicable) to your
designated dispensary? Yes No
(Checking Yes will al
low you to receive delivery services and your dispensary will be able to contact you about your
appointment(s), if needed. The VMR will ONLY provide your information to your dispensary.)
4.) ** CULTIVATION**
Do you plan on cultivating marijuana in the next 12 months? Yes No
If you selected Yes, the se
ction below MUST be completed.
Secure Indoor Facility Information:
Physical address (where marijuana will be cultivated): ______________________________________________________
Location within building: ___________________________________________________________________________
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------
OFFICE USE ONLY:
Funds #: _________________________ Amount: $_______ Funds Date: __________ Photo: Yes No Date: __________
HCP VERIFIED: Yes No D
ate: _____________ Caregiver: Approved Denied Initials: _____________ NOTES
: _____________________
_________________________________________________________________________________________________________________
_____________________________________________________________________________________________
State of Vermont
[phone] 802-241-5115
Department of Public Safety
Marijuana Registry
[fax] 802-241-5230
[email] DPS.MJRegistry@vermont.gov
Page 2
(Revised 08/2018)
__________________________________________________________________________________________________________________________________________________________________
Instructions: Read ALL the statements below. Once you have read all the statements, initial each statement signifying you
have read and understand the information. If you do not understand any of the statements below, contact the VMR.
5.) **
Patient Acknowledgements
**
______ I understand if my application is approved, my registration is valid for one year and
marijuana may only be used for
symptom relief.
______ I understand it is my responsibility to renew annually with the VMR by submitting the required c
ompleted application
with a non-refundable $50 fee to the VMR 30 days before my expiration date to prevent a lapse in status but no more
than 90 days before my expiration date.
______ I understand if I want a person to accom
pany m
e to the dispensary AND be present during my appointment in the
dispensing room he or she MUST register as my caregiver with the VMR.
______ I understand a lost or stolen registry identification card MUST be reported to the VMR within 10 business days.
______ I understand the use of marijuana is prohibited;
on the property of a registered dispensary; in any public place, while
operating a motor vehicle, boat, or any other motorized vehicle; in a workplace; operating heavy machinery or
handling a dangerous instrumentality; or that endangers the health or well-being of another person.
______ I understand if my application is denied the decision may be appealed within 7 days and is reviewed based on the
information s
ubmitted with this application and consultation with my Health Care Professional.
______ I understand the amount of marijuana a registered patient and their caregiver co
llectively may possess is no more
than 2 mature marijuana plants, 7 immature plants, and 2 ounces of usable marijuana at the same time.
______ I understand if my application is approved and want to cultivate, I MUST identify a single secure indoor facility on
this application.
______ I understand if my application is approved, I may purchase marijua
na and marijuana products, including seeds and
clones from my designated dispensary.
______ I understand if my application is approved, I MUST
present m
y valid registry identification card to dispensary
personnel at an appointment and at the time of delivery.
______ I understand if my application is approved, I may only change my designated dispensary once every 30 days.
______ I understand a Law Enforce
ment Officer is not required to return marijuana or paraphernalia after seizure.
______ I have instructed my registered caregiver(s) or next of kin, in the event of my death, they must notify the VMR within
72 hours.
______ I understand providing fa
lse information on this application or to Law Enforcement may result in criminal penalties.
______ I understand the possession and cultiva
tion of marijuana remains a violation of Federal Law.
______ I understand Vermont Law does not pro
vide protections against Federal Law violations and does not apply to conduct
that occurs outside of the State of Vermont.
______ I understand that my health insurer is not require
d to cover or reimburse the cost of marijuana for symptom relief.
_____________________________________________________________________________________________
State of Vermont
[phone] 802-241-5115
Department of Public Safety
Marijuana Registry
[fax] 802-241-5230
[email] DPS.MJRegistry@vermont.gov
Page 3
(Revised 08/2018)
__________________________________________________________________________________________________________________________________________________________________
6.) **Patient Photo Requirements**
Instructions: Initial applicants MUST submit a digital photo. Renewal applicants are not required to submit a digital photo,
unless your appearance has significantly changed.
Your photo must be:
In color;
Reflect your c
urrent appearance (taken within the last 6 months);
A clear image of ONLY you (not blurry, grainy, or fuzzy);
Full face-and-shoulder shot, squarely facing the camera (no sunglasses);
Additional Tips
Do n
ot scan your driver's license or another photo ID. The scanned image will not be of high enough quality to meet
the requirements.
Do not submit a photo of a photo (just take a photo of yourself)
.
Submitting a Photo – T
o submit a photo, send an email from your computer, cell phone, or mobile device with the following
information:
Subject Line: Your first and last name
Include your date of birth with your first and last name in the body of the email.
Attach your phot
o
Email Address: DPS.MJRegistry@vermont.gov
Receipt: A email will be sent by the VMR staff confirming acceptance of your photo.
If you are unable to email a photo, a phot
o may be submitted on a CD.
7.) **Patient Signature**
SIGNATURE REQUIRED
I declare under pains and penalty of perjury that the information provided on this form in its entirety is true and accurate.I
certify that I have read and understand the Registered Patient Acknowledgements.
**
Patient Applicant Signature: _______________________________________________ *
*
Date: ________________
ONLY REQUIRED FOR PATIENTS
UNDER 18 YEARS OLD
Or if the patient has a court appointed guardian or durable power of attorney:
I hereby warrant that I am a legally competent adult and a parent or court appointed guardian of the patient applicant and that I have
the right to contract for the patient applicant. I have read and fully understand the contents of this application and certify the
information provided on this application is true and accurate.
Parent or Guardian Signature: ___________________________________________________________________________
PRINT LEGAL NAME Last: ______________________________
_____ First: ___________________________ M.I. _____
Mailing Address: _____________________________________________________________________________________
City, State, Zip _______________________________________________________________________________________
If the patient applicant has a court appointed a guardian or durable power of attorney, please attach proof of guardianship or
power of attorney, if not previously submitted.
MAIL COMPLETED APPLICATIONS TO:
Department of Public Safety
Marijuana Registry
45 State Drive
Waterbury, VT 05671-1300
click to sign
signature
click to edit
click to sign
signature
click to edit
_____________________________________________________________________________________________
State of Vermont
[phone] 802-241-5115
Department of Public Safety
Marijuana Registry
[fax] 802-241-5230
[email] DPS.MJRegistry@vermont.gov
Page 4
(Revised 08/2018)
__________________________________________________________________________________________________________________________________________________________________
Registered Caregiver Designation (OPTIONAL)
Instructions: If the patient applicant wants to designate a caregiver, the following 3 pages must be completed by the person
the patient has selected. This section is not to be completed by the patient. A registered caregiver may assist one registered
patient with cultivation or obtaining marijuana from the patient’s designated dispensary. A registered caregiver may
accompany his or her patient to the dispensary and be present during appointments in the dispensing room. All caregiver
applications must be submitted with a $50 fee payable to the Department of Public Safety. This fee is in addition to the
fee for the patient application.
Note: Patient applicants under the age of 18 may register 2 caregivers; each caregiver must complete this section or complete
the “Registered Caregiver Application
”.
1.) **CAREGIVER APPLICANT INFORMATION**
Application Type
(check one)
: Initial Application
Renewal Application (ID #: _______________ Exp. Date: ________)
Full Legal Name: Last ____________________________ First ___
____________________________ M.I. ________
Maiden or Alias Name(s): __________________________________________________________________________
Mailing Address: _________________________________________________________________________________
City, State, Zip: _________________________________________ Telephone Number: ________________________
Physical Address
(if different than mailing)
: ______________________________________________________________
City, State, Zip: _______________________________________ Social Security Number: ______________________
Place of Birth (City/Town): ________________________________ State: ________ Country: ___________________
E-mail address: __________________________________________________________________________________
Gender (circle one): MALE FEMALE Eye Color: ___________ Weight: _______lbs. Height: ___ ft. _____ in.
Date of Birth: _____________ *VALID VERMONT Driver’s License or Non-Driver ID #: ___________________________
In addition to Vermont, I have resided or been employed in the following states (List all that apply): ______________
_______________________________________________________________________________________________
2.) **DISPENSARY COMMUNICATION & DELIVERY** (Dispensaries are REQUIRED to maintain ALL patient and
caregiver information as confidential in conformity with HIPAA. This authorization may be withdrawn at any time.)
May the Vermont Marijuana Registry (VMR) provide your address,
phone number, and email (if applicable) to your patient’s
designated dispensary?
Yes No
(By checking Yes you will be eligi
ble to receive delivery for your patient and the dispensary will be able to contact you about
appointment(s), if needed. ONLY the VMR and your dispensary will have your information.)
-----------------------------------------------------------------------------------------------------------------------------------------------
OFFICE USE ONLY: M.O./CK #: __________________________ Amount: $_____________ M.O. /CK Date: _______________
PHOTO: Yes
No Date: _____________ CHRC: Approved Denied Date: ______________ NOTES: __________________
_________________________________________________________________________________________________________
_____________________________________________________________________________________________
State of Vermont
[phone] 802-241-5115
Department of Public Safety
Marijuana Registry
[fax] 802-241-5230
[email] DPS.MJRegistry@vermont.gov
Page 5
(Revised 08/2018)
__________________________________________________________________________________________________________________________________________________________________
Instructions: Read ALL the statements below. Once you have read all the statements, initial each statement signifying you
have read and understand the information. If you do not understand any of the statements below, contact the VMR.
3.) **
Caregiver Acknowledgements
**
______ I understand a registered caregiver can only care for ONE registered patient and must be at least 21 years old.
______ I understand that applying as a caregiver indicates undertaking responsibility for managing my registered patient’s
well-being with respect to the use of marijuana for symptom relief. This may include assisting my registered patient
with cultivation or obtaining marijuana from their designated dispensary.
______ I understand if my application is approved, my registration is valid for one year.
______ I understand it is my responsibility to renew annually with the VMR by submitting the required completed application
with a non-refundable $50 fee to the VMR 30 days before my expiration date to prevent a lapse in status but no more
than 90 days before my expiration date.
______ I understand a lost or stolen registry identification card MUST be reported to the VMR within 10 business days.
______ I understand that I must consent to a criminal record check conducted by the VMR. The criminal record check includes
Vermont, out-of-state, and FBI criminal records.
______ I understand that if my application is denied due to a criminal conviction(s) a copy of the record will be sent to me for
review. The accuracy and completeness of the criminal record may be appealed in writing within 7 days.
______ I understand the amount of marijuana a registered patient and their caregiver collectively may possess is no more
than 2 mature marijuana plants, 7 immature plants, and 2 ounces of usable marijuana at the same time.
______ I understand that a registered caregiver is not authorized to use marijuana and my use of marijuana can be subject to
criminal penalties.
______ I understand if my application is approved, I MUST present my valid registry identification card to dispensary
personnel at an appointment and at the time of delivery.
______ I understand in the event of the death of my registered patient, I MUST notify the VMR within 72 hours and arrange
for the disposal of any marijuana or marijuana plants.
______ I understand that a Law Enforcement Officer is not required to return marijuana or paraphernalia after seizure.
______ I understand providing false information on this application or to Law Enforcement, may result in criminal penalties.
______ I understand Vermont Law does not provide protections against Federal Law violations and does not apply to conduct
that occurs outside of the State of Vermont.
_____________________________________________________________________________________________
State of Vermont
[phone] 802-241-5115
Department of Public Safety
Marijuana Registry
[fax] 802-241-5230
[email] DPS.MJRegistry@vermont.gov
Page 6
(Revised 08/2018)
__________________________________________________________________________________________________________________________________________________________________
4.) **Caregiver Photo Requirements**
Instructions: Initial applicants MUST submit a digital photo. Renewal applicants are not required to submit a digital photo,
unless your appearance has significantly changed.
Your photo must be:
In color;
Reflect your current appearance (taken within the last 6 months);
A clear image of ONLY you (not blurry, grainy, or fuzzy);
Full face-and-shoulder shot, squarely facing the camera (no sunglasses);
Additional Tips
Do not scan your driver's license or another photo ID. The scanned image will not be of high enough quality to meet
the requirements.
Do not submit a photo of a photo (just take a photo of yourself).
Submitting a Photo – To submit a photo, send an email from your computer, cell phone, or mobile device with the following
information:
Subject Line: Your first and last name
Include your date of birth with your first and last name in the body of the email.
Attach your photo
Email Address: DPS.MJRegistry@vermont.gov
Receipt: A email will be sent by the VMR staff confirming acceptance of your photo.
If you are unable to email a photo, a photo may be submitted on a CD.
5.) **Registered Caregiver Release Form**
SIGNATURE REQUIRED
I hereby acknowledge and consent to a review of any criminal records obtained from the Vermont Crime Information
Center, out-of-state law enforcement agencies, and the Federal Bureau of Investigation. I understand that the results will
be made available to the VMR for determining my eligibility as a registered caregiver, as specified in Title 18 V.S.A.
Chapter 86.
Additionally, I declare under pains and penalty of perjury that the information provided on this form is true and accurate
and that I have read and understood the Registered Caregiver Acknowledgements.
**Caregiver Applicant Signature: _______________________________________ **Date: ______________
MAIL COMPLETED APPLICATIONS TO:
Department of Public Safety
Marijuana Registry
45 State Drive
Waterbury, VT 05671-1300
click to sign
signature
click to edit
_____________________________________________________________________________________________
State of Vermont
[phone] 802-241-5115
Department of Public Safety
Marijuana Registry
[fax] 802-241-5230
[email] DPS.MJRegistry@vermont.gov
Page 7
(Revised 08/2018)
__________________________________________________________________________________________________________________________________________________________________
HEALTH CARE PROFESSIONAL VERIFICATION FORM
INSTRUCTIONS: This form must be completed by the patient applicant’s health care professional and signed within the
last 6 months. This form must be completed and submitted with a Registered Patient Application. The definitions below
are provided to assist health care professionals when completing this form.
This verification form is NOT considered a prescription and the only purpose of this verification form is
to confirm that the patient applicant has a debilitating medical condition as defined.
Notwithstanding any law to the contrary, a person who knowingly gives to any law enforcement officer false
information to avoid arrest or prosecution, or to assist another in avoiding arrest or prosecution, shall be
imprisoned for not more than one year or fined not more than $1,000.00 or both
.
DEFINITIONS:
“Bona fide health care professional-patient relationship” means:
A treating or consulting relationship of not less than three months’ duration, in the course of which a health care
professional has completed a full assessment of the registered patient’s medical history and current medical condition,
including a personal physical examination.
“Debilitating medical condition” means:
A) Cancer, multiple sclerosis, positive status for human immunodeficiency virus, acquired immune deficiency syndrome,
glaucoma, Crohn’s disease, Parkinson’s disease
or the treatment of these conditions, if the disease or the treatment
results in severe, persistent, and intractable symptoms;
B) Post-traumatic stress disorder, provided the Department confirms the applicant is undergoing psychotherapy or
counseling with a licensed mental health care provider; or
C) A disease or medical condition or its treatment that is chronic, debilitating and produces and one or more of the
following intractable symptoms: cachexia or wasting syndrome, chronic pain, severe nausea, or seizures.
“Health care professional” means an individual who is:
A) Licensed to practice medicine under 26 V.S.A Chapter 23 or Chapter 33;
B) Licensed as a naturopathic physician under 26 V.S.A. Chapter 81;
C) Certified as a physician assistant under 26 V.S.A. Chapter 31; or
D) Licensed as an advanced practice registered nurse under 26 V.S.A. Chapter 28.
This definition includes individuals who are professionally licensed under substantially equivalent provisions in New
Hampshire, Massachusetts, or New York.
Patients diagnosed with PTSD are also required to submit a completed
Mental Health Care Provider Form to the VMR.
An applicant without a “debilitating medical condition” is not eligible for a registry identification card.
_____________________________________________________________________________________________
State of Vermont
[phone] 802-241-5115
Department of Public Safety
Marijuana Registry
[fax] 802-241-5230
[email] DPS.MJRegistry@vermont.gov
Page 8
(Revised 08/2018)
__________________________________________________________________________________________________________________________________________________________________
HEALTH CARE PROFESSIONAL VERIFICATION FORM
The Vermont Marijuana Registry (VMR) will contact the health care professional completing this form to confirming the
accuracy of the information.
SECTIONS #1 – #6 MUST BE COMPLETED
and
submitted with a completed Registered Patient Application
This verification form is NOT considered a prescription and the only purpose of this verification form is to confirm that the patient
applicant has a debilitating medical condition as defined.
1) PATIENT INFORMATION (Please print legibly)
Full Legal Name: Last ______________________________ First __________________________________ M.I. ________
Date of Birth: _________________________________ Telephone Number: _______________________________________
2) HEALTH CARE PROFESSIONAL INFORMATION (Please print legibly)
Full Legal Name: Last ___________________________________ First ________________________________ M.I. _____
Office Mailing Address: ________________________________________________________________________________
City, State, Zip: ____________________________________________ Telephone Number: _________________________
3) HEALTH CARE PROFESSIONAL LICENSE INFORMATION:
License Number: ______________________________ Issuing State (circle one): VT NH MA NY
4) LICENSURE CATEGORY
Doctor of Medicine Osteopathic Physician Naturopathic Physician
Physician Assistant Advanced Practice Registered Nurse
5) VERIFICATION OF A DEBILITATING MEDICAL CONDITION
(A) Does the patient applicant have a debilitating medical condition as defined on the Cover Sheet?
No Yes (if “Yes”, Section B MUST be completed)
(B) The patient applicant I am treating or consulting has been diagnosed with (check all that apply):
Acquired Immune Deficiency Syndrome
Cancer
Crohn’s Disease
Glaucoma
Human Immunodeficiency Virus
Multiple Sclerosis
Parkinson’s Disease
*Post-Traumatic Stress Disorder
(*A Mental Health Care Provider Form is required to be completed and submitted to the VMR)
A disease or medical condition or its treatment that is chronic, debilitating, and produces one or more of the
following intractable symptoms listed in subdivision B. (**Subsections I and II MUST be completed**)
I.) **Indicate specific diagnosis**: _____________________________________________________________
II.) **Indicate specific symptom** (circle all that apply):
cachexia chronic pain severe nausea seizures
------------------------------------------------------------------------------------------------------------------------------------------------------
OFFICE USE ONLY – HCPF VERIFIED:
Yes No
DATE: ______/______/_________ NOTES: ____________________________________
_________________________________________________________________________________________________________
_____________________________________________________________________________________________
State of Vermont
[phone] 802-241-5115
Department of Public Safety
Marijuana Registry
[fax] 802-241-5230
[email] DPS.MJRegistry@vermont.gov
Page 9
(Revised 08/2018)
__________________________________________________________________________________________________________________________________________________________________
6) BONA FIDE HEALTH CARE PROFESSIONAL-PATIENT RELATIONSHIP INFORMATION
(A) Have you completed a full assessment of the patient applicant’s medical history and current medical condition,
including a personal physical examination?
Yes No
(B) Do you have a treating or consulting relationship with the patient application of at least three (3) months?
Yes No
(C) Has the patient applicant been diagnosed with a terminal illness and/or currently under hospice care?
Yes No
(D) Was the patient applicant diagnosed in another state or jurisdiction where they formally resided and moved to
Vermont within the last three (3) months?
Yes No
(E) Was the patient applicant diagnosed with the debilitating medical condition specified on the previous page within
the last three (3) months?
Yes (Date of diagnosis: _____/_____/_______) No
(F) Was the patient applicant referred to you by another health care professional because of your advanced education
and clinical training specific to the debilitating medical condition specified on the previous page?
Yes No
7) HEALTH CARE PROFESSIONAL SIGNATURE
I certify that:
(A) I am a health care professional;
A) Licensed to practice medicine under 26 V.S.A Chapter 23 or Chapter 33;
B) Licensed as a naturopathic physician under 26 V.S.A. Chapter 81;
C) Certified as a physician assistant under 26 V.S.A. Chapter 31; or
D) Licensed as an advanced practice registered nurse under 26 V.S.A. Chapter 28; or,
E) Professional licensed under substantially equivalent provisions in NH, MA, or NY.
(B) I am in good standing with the state (VT, NH, MA, or NY) regulating my professional license, and that the facts stated on
this Health Care Professional Verification Form are true and accurate to the best of my knowledge and belief.
(C) I understand, notwithstanding any law to the contrary, a person who knowingly provides false information on this
application may be guilty of perjury and imprisoned for not more than one year or fined not more than $1,000.00 or both.
This penalty shall be in addition to any other penalties that may apply.
This verification form is not considered a prescription and that the only purpose of this verification form is to confirm
that the applicant patient has a debilitating medical condition.
Health Care Professional’s Signature: _______________________________________ Date: _________________________
This form must be completed and submitted with a Registered Patient Application to:
Department of Public Safety
Marijuana Registry
45 State Drive
Waterbury, VT 05671-1300
_____________________________________________________________________________________________
State of Vermont
[phone] 802-241-5115
Department of Public Safety
Marijuana Registry
[fax] 802-241-5230
[email] DPS.MJRegistry@vermont.gov
Page 10
(Revised 08/2018)
__________________________________________________________________________________________________________________________________________________________________
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
THIS SECTION MUST BE COMPLETED BY THE PATIENT APPLICANT
I hereby authorize the health care professional, and mental health care provider, if applicable, named on this form to release my
protected medical information to the Vermont Marijuana Registry (VMR) to verify and confirm the accuracy of the information
contained within this form. I authorize the named health care professional, and mental health care professional, if applicable, to:
Disclose the nature, symptoms, and duration of the medical condition identified on this form for the purpose of determining
that it meets the legal definition of a debilitating medical condition on page 1 of this form;
Disclose whether the named health care professional, and mental health care professional, if applicable, and I have a bona
fide health care professional-patient relationship, as defined by law and on page 1 of this form;
Confirm the accuracy of the information contained in this form.
I understand that any information released to the VMR will be used solely to confirm the accuracy of the information contained
in this form. While the information will no longer be covered by the HIPAA Privacy Rule, Vermont law
requires the VMR to keep
all information confidential, except for the prosecution of false swearing. I understand this authorization is valid for one year from
the date the VMR receives this form, unless a written communication revoking this authorization or a new authorization is received
by the VMR. I understand that I have the right to revoke this authorization at any time by notifying both the health care professional
named on this form and to the VMR in writing.
Patient Applicant Signature REQUIRED: _______________________________________________ Date: ____________
If the patient applicant is under the age of 18 or has a court appointed guardian the section below must be completed:
Parent or Guardian Signature: __________________________________________________________ Date: ____________
MAIL COMPLETED APPLICATIONS TO:
Department of Public Safety
Marijuana Registry
45 State Drive
Waterbury, VT 05671-1300
Questions?
Contact the Marijuana Registry
Phone: (802) 241-5115
Email: DPS.MJRegistry@vermont.gov
Website: www.medicalmarijuana.vermont.gov
_____________________________________________________________________________________________
State of Vermont
[phone] 802-241-5115
Department of Public Safety
Marijuana Registry
[fax] 802-241-5230
[email] DPS.MJRegistry@vermont.gov
Page 11
(Revised 08/2018)
__________________________________________________________________________________________________________________________________________________________________
MENTAL HEALTH CARE PROVIDER FORM
(REQUIRED FOR PATIENTS WITH PTSD INDICATED ON THE HEALTH CARE PROFESSIONAL VERIFICATION FORM.)
Instructions: This form must be completed and submitted for all applicants with Post-Traumatic Stress Disorder (PTSD)
identified as the only debilitating medical condition on the Health Care Professional Verification Form. Vermont law
requires the Vermont Marijuana Registry (VMR) to confirm applicants with PTSD are undergoing psychotherapy, or
counseling with a licensed mental health care provider. The VMR may contact the mental health care provider
completing this form to confirm the accuracy of the information contained on this form.
“Mental Health Care Provider” means:
“A person license to practice medicine who specializes in the practice of psychiatry; a psychologist, a
psychologist-doctorate, or a psychologist-master as defined in 26 V.S.A. § 3001; a clinical social worker as defined in
26 V.S.A. § 3201; or a clinical mental health counselor as defined in 26 V.S.A. § 3261.”
1. Patient Information
Last Name: ______________________________ First Name: __________________________ M.I. ____
Date of Birth: ______________________________ Telephone Number: _________________________
2. Mental Health Care Professional Information
Last Name: ______________________________ First Name: __________________________ M.I. ____
Business Mailing Address: ______________________________________________________________
City, State, Zip Code: _______________________________ Telephone Number: __________________
3. Licensure Information (**Subsections A and B MUST be completed**)
A. Psychologist Psychologist-doctorate Psychologist-master
Psychiatrist Clinical social worker Clinical mental health counselor
Advanced Practice Registered Nurse (with Adult Psych and Mental Health Specialty)
B. License Number: ______________________________
4. Verification
I certify I am providing psychotherapy and/or counseling to the aforementioned patient. I declare under pains and
penalty of perjury that the information provided on this form in its entirety is true and accurate.
SIGNATURE: ____________________________________________________________ DATE: _________________________
MAIL COMPLETED APPLICATIONS TO:
Department of Public Safety
Marijuana Registry
45 State Drive
Waterbury, VT 05671-1300
-------------------------------------------------------------------------------------------------------------------------------------------------------------
OFFICE USE ONLY: Notes: ___________________________________________________________________________________________
____________________________________________________________________________________________________________________
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PATIENT REGISTRATION PACKET (Vermont)

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Completed 17 June 2021

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