Fillable Replacement 329 (Do not submit this document to (Hawaii)

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Replacement 329 (Do not submit this document to (Hawaii)

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  • 113 check-boxes
  • 61 other fields

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File type: PDF

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Medical Cannabis Registry Program
In accordance with Hawaii Revised Statutes 329-123 (b) “Qualifying patients shall report changes in information within ten working
days.” This form must be signed by the registered patient or by the appropriate parent, guardian, or legal custodian, as applicable, if
the registered patient is a minor or adult lacking legal capacity. It is your responsibility to notify your certifying physician of any
changes to your information.
CHANGE FORM PACKET CHECKLIST
(Do not submit this document to DOH)
STEP 1. SELECT the
type of change.
STEP 2. COMPLETE the sections of the
change form packet indicated below.
STEP 3. SUBMIT all of the following items
below.
A. Request a
Replacement 329
Card:
(A new card will be
issued)
Section 329
#1: Request a Replacement 329 Card
329A: Applicant Certification
Clear copy of the Applicant’s ID
One (1) Money Order or Cashier’s Check
for $16.50 per change form packet
Completed Change Form Packet (must
submit all 5 pages)
B. Request to Void
My 329 Card:
Section 329
#2: Void 329 Card
329A: Applicant Certification
Clear copy of the Applicant’s ID
Completed Change Form Packet (must
submit all 5 pages)
C. Request to
Update or Add
Applicant’s
Contact
Information
Section 329
#4: Update Applicant’s Contact Info.
329A: Applicant Certification
Clear copy of the Applicant’s ID
Completed Change Form Packet (must
submit all 5 pages)
D. Request to
Update or Add
Caregiver’s
Contact
Information
Section 329
#5: Update Caregiver’s Contact Info.
329A: Applicant Certification
Clear copy of the Applicant’s ID
Completed Change Form Packet (must
submit all 5 pages)
E. Request to Add
OR Change a
Caregiver: My
grow site WILL
change.
(A new card will be
issued)
Section 329
#5: Update Caregiver’s Contact Info.
#6: Add, Change, Remove a Caregiver
#7: Add, change, or Remove Grow Site
329A: Applicant Certification
6A. Caregiver’s Certification
7A. Grow Site Certification
Clear copy of the Applicant’s ID
Clear copy of the new Caregiver’s ID
One (1) Money Order or Cashier’s Check
for $16.50 per change form packet
Completed Change Form Packet (must
submit all 5 pages)
F. Request to
Remove a
Caregiver: My
grow site WILL
change.
(A new card will be
issued)
Section 329
#6: Add, Change, Remove a Caregiver
#7: Add, change, or Remove Grow Site
329A: Applicant Certification
7A. Grow Site Certification
Clear copy of the Applicant’s ID
One (1) Money Order or Cashier’s Check
for $16.50 per change form packet
Completed Change Form Packet (must
submit all 5 pages)
G. Request to Add
OR Change a
Caregiver: My
grow site will
NOT change.
(A new card will be
issued)
Section 329
#5: Update Caregiver’s Contact Info.
#6: Add, Change, Remove a Caregiver
329A: Applicant Certification
6A. Caregiver’s Certification
Clear copy of the Applicant’s ID
Clear copy of the new Caregiver’s ID
One (1) Money Order or Cashier’s Check
for $16.50 per change form packet
Completed Change Form Packet (must
submit all 5 pages)
STEP 1. SELECT the
type of change.
STEP 2. COMPLETE the sections of the
change form packet indicated below.
STEP 3. SUBMIT all of the following items
below.
H. Request to
Remove a
Caregiver: My
grow site will
NOT change.
(A new card will be
issued)
Section 329
#6: Add, Change, Remove a Caregiver
329A: Applicant Certification
Clear copy of the Applicant’s ID
One (1) Money Order or Cashier’s Check
for $16.50 per change form packet
Completed Change Form Packet (must
submit all 5 pages)
I. Request to Add,
Change, or
Remove Grow
Site
(A new card will be
issued)
Section 329
#7: Add, change, or Remove Grow Site
329A: Applicant Certification
7A. Grow Site Certification
Clear copy of the Applicant’s ID
One (1) Money Order or Cashier’s Check
for $16.50 per change form packet
Completed Change Form Packet (must
submit all 5 pages)
J. Request to
Change My
Name (or
Caregiver’s
Name) and/or
Date of Birth
(A new card will be
issued)
Section 329
#3: Name and/or Date of Birth Change
329A: Applicant Certification
If your name was legally changed:
Clear copy of the Applicant’s old ID card
(before the legal name change) and,
Clear copy of the Applicant’s NEW ID card
showing your new legal name.
One (1) Money Order or Cashier’s Check
for $16.50 per change form packet
Completed Change Form Packet (must
submit all 5 pages)
If your Caregiver’s name was legally changed:
Clear copy of the Caregiver’s old ID card
(before the legal name change) and,
Clear copy of the Caregiver’s NEW ID card
showing your new legal name and,
Clear copy of the Applicant’s ID
One (1) Money Order or Cashier’s Check
for $16.50 per change form packet
Completed Change Form Packet (must
submit all 5 pages)
If either Applicant and/or Caregiver’s name(s)
or date of birth information was entered
incorrectly online:
Clear copy of the Applicant’s ID
Clear copy of the Caregiver’s ID (if
applicable)
One (1) Money Order or Cashier’s Check
for $16.50 per change form packet
Completed Change Form Packet (must
submit all 5 pages)
STATE OF HAWAII
DEPARTMENT OF HEALTH
4348 Waialae Avenue, #648
Honolulu, Hawaii 96816
Medical Cannabis Registry Program
In accordance with Hawaii Revised Statutes 329-123 (b) “Qualifying patients shall report changes in information within ten working
days.” This form must be signed by the registered patient or by the appropriate parent, guardian, or legal custodian, as applicable, if
the registered patient is a minor or adult lacking
legal capacity. It is your responsibility to notify your certifying physician of any
changes to your information.
Please submit this page to DOH
329 Change Form Packet
Only the Registered Applicant/Patient Can Request Changes
Section 329
This REQUEST is for the 329 Registration Card #:
OR 6 digit Application #:
Applicant Name: as it appears on my current 329 Registration Card
First Name:
Middle Name:
Last Name:
Current Caregiver Name (if applicable): as it appears on my current 329 Registration Card
First Name:
Middle Name:
THIS IS A REQUEST TO (select ALL that apply and fill out all corresponding sections):
1. Request a Replacement 329 Card (lost, stolen, or damaged)
2. Void 329 Card
3. Name and/or Date of Birth Change
4. Add or Update Applicant’s Contact Information
1. Request a Replacement 329 Card
Yes No: My card has been lost, stolen, or damaged. Please reissue my 329 card.
2. Void 329 Card
Select one of the following below:
The applicant no longer has a debilitating condition
The applicant is moving out of state
The applicant has a firearm permit
The applicant will be applying for a firearm permit
Applicant is no longer benefiting from the use of medical cannabis
Other (please describe):
*If the patient is deceased, the certifying physician must fill out a separate form: “Void Request by Physician”
Mail your completed packet to: Medical Cannabis Registry, 4348 Waialae Ave, #648, Honolulu, HI
96816
The Change Form Packet (2021) If the packet is incomplete or inconsistent it will be returned. Page 1 of 5
Medical Cannabis Registry Program
In accordance with Hawaii Revised Statutes 329-123 (b) “Qualifying patients shall report changes in information within ten working
days.” This form must be signed by the registered patient or by the appropriate parent, guardian, or legal custodian, as applicable, if
the registered patient is a minor or adult lacking legal capacity. It is your responsibility to notify your certifying physician of any
changes to your information.
Please submit this page to DOH.
CBD-329 – The Change Form Packet (2021)
If the packet is incomplete or inconsistent it will be returned.
Page 2 of 5
3. Name and/or Date of Birth Change
Patient Name as it will appear on the NEW Registration Card (MUST be exactly as it appears on the supporting ID)
First Name:
Middle Name:
Last Name:
Patient Date of Birth from:
Change Patient Date of Birth to:
Current Caregiver Name (if applicable): as it will appear on the NEW Registration Card (MUST be exactly as it appears
on the supporting ID) editing your caregivers name in this section does not mean you are adding or changing your caregiver.
First Name:
Middle Name:
Last Name:
Caregiver Date of Birth from:
Change Caregiver Date of Birth to:
4. Add or Update Applicant’s Contact Information
Select and make changes to all that apply below
Update
Residence Address
to:
Update
Mailing
Address To:
Update Phone Number to:
Update Email Address to:
5. Add or Update Caregiver’s Contact Information
Caregiver’s Name (as stated on their ID)
Select and make changes to all that apply below
Update or Add Update or
Residence Address Add Mailing
to: Address To:
Update or Add
Phone Number to:
Update or Add
Email Address to:
*Please see the appendix for updating an applicant's email address.
Medical Cannabis Registry Program
In accordance with Hawaii Revised Statutes 329-123 (b) “Qualifying patients shall report changes in information within ten working
days.” This form must be signed by the registered patient or by the appropriate parent, guardian, or legal custodian, as applicable, if
the registered patient is a minor or adult lacking legal capacity. It is your responsibility to notify your certifying physician of any
changes to your information.
Please submit this page to DOH.
The Change Form Packet (2021) If the packet is incomplete or inconsistent it will be returned.
Page 3 of 5
6. Add, Change, or Remove a Caregiver
Select one of the following options below:
Add a Caregiver (no previous caregiver).
Change my caregiver. I revoke my current caregiver (listed below) and designate the following individual (listed below)
as my new primary caregiver.
Revoke my caregiver. I will not designate a new caregiver.
I hereby revoke my current designation of:
First Name
Middle Name
Last Name
Caregiver Name exactly as it appears on the 329 Registration Card
I would like to designate the following individual as my primary caregiver for the medical use of cannabis:
First Name
Middle Name
Last Name
New Caregiver’s name must be exactly as it appears on their government issued identification card.
Valid Photo ID Required. Complete identification information below if adding or changing your caregiver.
Driver’s License
State Identification
Passport Book
State or Country of issue:
ID Number:
Expiration Date:
Gender:
Male, Female,
Date of Birth:
Not specified
7. Add, Change, or Remove Grow Site
Step 1. Select one of the following options below:
Step 2. Select one of the following options below:
Add a grow site (no previous grow site).
Applicant/Patient will grow own medical cannabis
Change the current grow site to a new grow site.
Primary Caregiver will grow medical cannabis
for the Applicant/Qualifying Patient
Remove the current grow site on my 329
registration card (no new grow site).
Neither Applicant/Qualifying Patient NOR primary
caregiver will grow medical cannabis
Step 3. Select one of the following options below:
The NEW site is owned or controlled by the PATIENT and is the:
(Patient must select one of the following, if applicable)
Patient’s residence address, OR
Patient’s residence address, and mailing address, OR
Patient’s Other address
OR the NEW site is owned and controlled by the CAREGIVER and is the: (Caregiver
must select one of the following, if applicable)
Caregiver’s residence address, OR
Caregiver’s residence address and mailing address, OR
Caregiver’s Other address
NEW Grow Site Address:
(if applicable)
Medical Cannabis Registry Program
In accordance with Hawaii Revised Statutes 329-123 (b) “Qualifying patients shall report changes in information within ten working
days.” This form must be signed by the registered patient or by the appropriate parent, guardian, or legal custodian, as applicable, if
the registered patient is a minor or adult lacking legal capacity. It is your responsibility to notify your certifying physician of any
changes to your information.
Please submit this page to DOH.
The Change Form Packet (2021) If the packet is incomplete or inconsistent it will be returned.
Page 4 of 5
329A. APPLICANT’S STATEMENT OF UNDERSTANDING AND CERTIFICATION
I CERTIFY that :
1) I have read, understand, and agree to part IX, chapter 329, Hawaii Revised Statutes (HRS): Medical Use of
Cannabis;
2) I have a debilitating medical condition(s), as defined therein, and as stated in section C of this application;
3) My use of cannabis is solely for the treatment of the specified debilitating medical condition;
4) I agree to abide by the Conditions of Use as outlined in part IX, section 329-122, HRS, as well as ALL other
applicable sections of part IX, chapter 329, HRS; chapter 11-160 HAR, and all other applicable laws for the
medical use of cannabis in the State of Hawaii.
Under penalty of perjury, I attest that all information submitted is true to the best of my understanding
and that I have not intentionally furnished false or fraudulent information or omitted any information
from this application. By signing this document I acknowledge that I am subject to part IX, chapter 329, HRS,
chapter 11-160 HAR, and all other applicable laws for the medical use of cannabis in the State of Hawaii. I
understand that my registration as a qualified patient to use medical cannabis under Hawaii law may not protect
me against arrest, prosecution, or conviction under Federal law.
Print Applicant (or Legal Guardian) Name
Applicant (or Legal Guardian) Signature
Date
6A. NEW 329 CAREGIVER’S STATEMENT OF UNDERSTANDING AND CERTIFICATION
I CERTIFY that :
1)
I have read and understand part IX, chapter 329, HRS: Medical Use of Cannabis;
2)
I agree to undertake responsibility for managing the well-being of the qualifying patient, so named as the applicant on
this application, with respect to the medical use of cannabis;
3)
I agree to abide by the Conditions of Use as outlined in part IX, section 329-122, HRS, as well as ALL other applicable
sections of part IX, chapter 329, HRS, chapter 11-160, HAR, and all other applicable laws for the medical use of
cannabis in the State of Hawaii; and
4)
I understand that in accordance with part IX, chapter 329, HRS, medical cannabis can only be grown at one location, as
designated in Section E of this application.
Under penalty of perjury, I attest that all information submitted is true to the best of my understanding and that I have not
intentionally furnished false or fraudulent information or omitted any information from this application. By signing this
document I acknowledge that I am subject to part IX, chapter 329, HRS, chapter 11-160, HAR, and all other applicable laws for the
medical use of cannabis in the State of Hawaii. I understand that even though I am following Hawaii state laws regarding primary
caregivers of medical cannabis patients, I may not be protected against arrest, prosecution, or conviction under Federal law.
Print Caregivers Name
Caregiver’s Signature
Date
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signature
click to edit
click to sign
signature
click to edit
Medical Cannabis Registry Program
In accordance with Hawaii Revised Statutes 329-123 (b) “Qualifying patients shall report changes in information within ten working
days.” This form must be signed by the registered patient or by the appropriate parent, guardian, or legal custodian, as applicable, if
the registered patient is a minor or adult lacking legal capacity. It is your responsibility to notify your certifying physician of any
changes to your information.
Please submit this page to DOH.
The Change Form Packet (R.4.12.21) If the packet is incomplete or inconsistent it will be returned.
Page 5 of 5
7A. GROW SITE CERTIFICATION
APPLICANT’S STATEMENT OF UNDERSTANDING AND CERTIFICATION (This section MUST be signed by
applicant, regardless of intent to grow. If applicant is a minor or adult lacking legal capacity, this section MUST be
signed by the parent, guardian or legal custodian, as applicable)
I, the applicant/qualifying patient, CERTIFY that :
1. I plan to grow (or NOT grow) my medical cannabis, as indicated on the previous page.
2. If I’ve indicated a grow site location other than my residence (an “Other Address”) AND I’ve indicated that I either
own or control the “Other Address”, as evidenced by my initials where applicable, I attest that I either own or
control the stated grow site location.
Under penalty of perjury, I attest that all information submitted is true to the best of my understanding and that I
have not intentionally furnished false or fraudulent information or omitted any information from this application.
By signing this document I acknowledge that I am subject to part IX, chapter 329, HRS, chapter 11-160, HAR, and all
other applicable laws for the medical use of cannabis in the State of Hawaii. I understand that my registration as a
qualified patient to use medical cannabis under Hawaii law may not protect me against arrest, prosecution, or conviction
under Federal law.
Print Applicant (or Legal Guardian) Name
Applicant (or Legal Guardian)
Signature
Date
CAREGIVER’S STATEMENT OF UNDERSTANDING AND CERTIFICATION (MUST be signed by primary
caregiver IF designated to grow or IF primary caregiver either owns or controls the grow site location)
I, the primary caregiver, CERTIFY that :
1. I understand and acknowledge that:
(Select one of the following below)
I have been designated to grow medical cannabis by the aforementioned qualifying patient, OR
The qualifying patient will grow on a site that I own or control; AND
2. If I’ve indicated a grow site location other than my residence AND I’ve indicated that I either own or control the
“Other Address”, as evidenced by my initials above, I ATTEST that I either own or control the stated grow site
location.
3. If I’ve indicated a grow site location that I own or control, I am responsible for ensuring that the grow site location
remains compliant with part IX, chapter 329, HRS, specifically any limitations to “adequate supply”.
Under penalty of perjury, I attest that all information submitted is true to the best of my understanding and that I have not
intentionally furnished false or fraudulent information or omitted any information from this application. By signing this
document I acknowledge that I am subject to part IX, chapter 329, HRS, chapter 11-160, HAR, and all other applicable laws for the
medical use of cannabis in the State of Hawaii. I understand that even though I am following Hawaii state laws regarding the medical
use of cannabis, I may not be protected against arrest, prosecution, or conviction under Federal law.
Print Caregiver’s Name
Caregiver’s Signature
Date
click to sign
signature
click to edit
click to sign
signature
click to edit
Medical Cannabis Registry Program
In accordance with Hawaii Revised Statutes 329-123 (b) “Qualifying patients shall report changes in information within ten working
days.” This form must be signed by the registered patient or by the appropriate parent, guardian, or legal custodian, as applicable, if
the registered patient is a minor or adult lacking legal capacity. It is your responsibility to notify your certifying physician of any
changes to your information.
Updating Patient Email Address for your Medical Cannabis Registry Login
P
ayment is required for the following changes:
• Request a Replacement 329 Card (lost, stolen, or damaged)
• Name and/or Date of Birth Change
• Add, Change or Remove Caregiver
• Add, Change, or Remove Grow Site
Please do not forget to submit:
• All 5 pages of the change packet that are indicated to be submitted to DOH
• Copy of the applicant’s photo ID to verify that the change packet is yours
• Copy of your Caregiver’s photo ID (if applicable)
• A money order or cashier’s checks of $16.50 Payable to “DOH” (if applicable)
• DO NOT SEND PERSONAL CHECKS OR CASH
Ma
il your completed change packet and supporting documents to:
Medical Cannabis Registry
4348 Waialae Avenue, #648
Honolulu, Hawaii 96816
If you have requested to update your email address, program staff will make the requested updates in your record. However,
Please be advised that this does not change your Medical Cannabis Registry login information at https://medmj.ehawaii.gov.
In order to update your login information to use your new email address, please follow the steps below.
1. Go to https://login.ehawaii.gov and login using your OLD email address and current password
2. Click “My Account” in the top right corner- a drop down list will appear
3. Choose the “Update Account” option
4. Scroll down to Contact Information and input your new email address
5. Click “Save”
You may also call our IT Help desk at 808-695-4620 for assistance. If you have any further questions or concerns please
feel free to email our program at medicalcannabis@doh.hawaii.gov.
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Replacement 329 (Do not submit this document to (Hawaii)

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Completed 21 August 2021

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