Fillable PHYSICIAN CERTIFICATION FORM (Missouri)

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PHYSICIAN CERTIFICATION FORM (Missouri)

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MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
SECTION FOR MEDICAL MARIJUANA REGULATION
MEDICAL MARIJUANA REGULATORY PROGRAM
PHYSICIAN CERTIFICATION FORM
INSTRUCTIONS
This form does not constitute a prescription for medical marijuana.
This form should be completed in its entirety for qualifying patients who do not require more than the standard amount of four
ounces of medical marijuana per month. If a higher amount is required, please complete Physician Certication Form MO 580-3277.
The date of the physician certication must be no earlier than thirty (30) days before the date the patient will apply for a patient
identication card or renewal. Please see instructions below for further details regarding: [1] physician name, [2] license type, and
[3] physician signature.
QUALIFYING PATIENT INFORMATION
PHYSICIAN INFORMATION
LAST NAME FIRST NAME MIDDLE NAME
SOCIAL SECURITY NUMBER DATE OF BIRTH (MM-DD-YYYY)
IS THE PATIENT 18 YEARS OR OLDER?
Yes No
PHYSICIAN NAME AS APPEARS ON LICENSE [1] E-MAIL ADDRESS
LICENSE TYPE [2] MISSOURI ISSUED LICENSE NUMBER OFFICE PHONE NUMBER
MD DO
OFFICE ADDRESS CITY STATE ZIP CODE COUNTY
Cancer
Epilepsy
Glaucoma
Intractable migraines unresponsive to other treatment
A chronic medical condition that causes severe, persistent pain or persistent muscle spasms, including but not limited to those
associated with multiple sclerosis, seizures, Parkinson’s disease, and Tourette’s syndrome (Please specify underlying chronic
medical condition): _______________________________________
Debilitating psychiatric disorders, including, but not limited to, post-traumatic stress order, if diagnosed by a state licensed psychiatrist
(Diagnosing psychiatrist): _______________________________________
Human immunodeficiency virus or acquired immune deficiency syndrome
A chronic medical condition that is normally treated with a prescription medication that could lead to physical or psychological
dependence, when a physician determines that medical use of marijuana could be effective in treating that condition and would serve
as safer alternative to the prescription medication.
(Please specify chronic medical condition): _______________________________________
A terminal illness (Please specify the terminal illness): _______________________________________
In the professional judgment of a physician, any other chronic, debilitating or other medical condition, including, but not limited to,
hepatitis C, amyotrophic lateral sclerosis, inflammatory bowel disease, Crohn’s disease, Huntington’s disease, autism, neuropathies,
sickle cell anemia, agitation of Alzheimer’s disease, cachexia, and wasting syndrome (Please specify debilitating disease or
medical condition): _______________________________________
MO 580-3305 (2-2020) DHSS-MMRP-09 (2-2020)
QUALIFYING PATIENT’S QUALIFYING MEDICAL CONDITION
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ATTESTATION AND AGREEMENT
I, _______________________________________, the physician:
(PRINT NAME)
1. In the case of a non-emancipated qualifying patient under the age of eighteen (18), have received the written consent of a custodial
parent or legal guardian who will serve as a primary care giver for the qualifying patient.
Initial: _______
2. Have met with and examined the qualifying patient. Date of Examination: _______________________________________
Initial: _______
3. Have reviewed the qualifying patient’s medical records or medical history and the qualifying patient’s current medications and allergies
to medications.
Initial: _______
4. Have discussed with the qualifying patient, or the qualifying patient’s custodial parent or legal guardian, the patient’s current symptoms.
Initial: _______
5. Have created a medical record for the qualifying patient regarding the meeting and am maintaining the qualifying patient’s medical
record as required in 334.097, RSMo.
Initial: _______
6. Have discussed with the qualifying patient, or the qualifying patient’s custodial parent or legal guardian, risks associated with medical
marijuana including known contraindications applicable to the patient
Initial: _______
7. Have discussed with the qualifying patient, or the qualifying patient’s custodial parent or legal guardian, the risks of medical marijuana
use to fetuses and the risks of medical marijuana use to breast feeding infants.
Initial: _______
PHYSICIAN’S ATTESTATION
I, _______________________________________, in my professional opinion, believe the qualifying patient suffers from a qualifying medical
condition as defined in 19 CSR 30-95.010. I attest that the information provided in this written certification is true and correct.
PHYSICIAN SIGNATURE [3] DATE
[1] Physician name must be entered as it appears in the records of the Missouri Division of Professional Registration. Please contact
medicalmarijuanainfo@health.mo.gov for more information.
[2] Physician is an individual who is licensed and in good standing to practice medicine or osteopathy under Missouri law. A license is in
good standing if it is registered with the Missouri Board of Healing Arts as current, active, and not restricted in any way, such as by
designation as temporary or limited. 19 CSR 30-95.010.
[3] Signature should be handwritten, rather than typed.
MO 580-3305 (2-2020) DHSS-MMRP-09 (2-2020)
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PHYSICIAN CERTIFICATION FORM (Missouri)

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Completed 23 September 2020

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