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Designation Form (Fillable) .pdf


Original filename: Designation Form (Fillable).pdf
Author: Givens, Choanna

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STATE OF MAINE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Maine Center for Disease Control and Prevention

Medical Use of Marijuana Program
Designation Form

SECTION 1: Qualifying Patient Information
Legal Name:
Date of Birth:

Telephone Number: (

)

Home Address:
City:

State:

Zip:

County:

Medical Provider Written Certification:
Issued Date: ___________________

Expiration Date: ___________________

SECTION 2: Cultivation Designation
_______ # of plants I will cultivate
_______# of plants my caregiver will cultivate
_______# of plants my dispensary will cultivate
Total # (Not to exceed 6) _________
Visiting qualifying patient (must be included as 1 of the 5 patients allowed per caregiver)
Non cultivating caregiver
A patient may designate either a primary caregiver or a dispensary to cultivate
For questions regarding this program, please contact the following:
Department of Health and Human Services
Maine Center for Disease Control and Prevention
Maine Medical Use of Marijuana Program
286 Water Street
11 State House Station
Augusta, ME 04333-0011
Tel: (207) 287-8016
Fax: (207) 287-2671
TTY Users: Dial 711 (Maine Relay)
Email: dhhs.mmmp@maine.gov
Website: www.mainepublichealth.gov/mmm

Page 1 of 3

Form 110103 Rev 11/2016

SECTION 3A: Cultivating Caregiver Information
Legal Name:
Telephone Number: (

)

Mailing Address:
City:

State:

Zip:

County:

Caregiver MMMP Registration # assigned to this patient:
Primary Caregiver is not required to register: Specify exception:
Start Date:

End Date:

Termination of Designation Date:

SECTION 3B: Non Cultivating Caregiver Information
Legal Name:
Telephone Number: (

)

Mailing Address:
City:

State:

Zip:

County:

Caregiver MMMP Registration # assigned to this patient:
Primary Caregiver is not required to register: Specify exception:
Start Date:

End Date:

Termination of Designation Date:

SECTION 4: Dispensary Information
Name of Dispensary:
Physical Address:

Telephone Number: (

)

Name of Dispensary Representative:
Start Date:

Page 2 of 3

End Date:

Termination of Designation Date:

Form 110103 Rev 11/2016

SECTION 5: Patient Rights and Responsibilities
• My provider has certified that I have a condition that entitles me to participate in the Maine Medical Use of
Marijuana Program until ___________________. I have provided you with a copy of my Maine Medical Use of
Marijuana Program identification card/MMMP certification and my original designation card as proof that I am
authorized to participate in the program. I have also provided you a copy of my Maine issued driver license or other
Maine issued photo identification card as proof of my identity.
• If I am visiting from another state, I have provided you with a copy of the medical use of marijuana certification
issued by my state of ________________ as evidence that I live in a state that authorizes marijuana for medical
purposes and have a debilitating condition authorized under Maine law. I have also provided you with a copy of my
Maine provider certification and a copy of my photographic identification card or driver’s license from my home
jurisdiction. As a visiting qualifying patient, I agree to abide by all terms and conditions of the Maine Medical Use of
Marijuana Program.
You are hereby authorized to share this caregiver designation form and any copies of documents that I am required to
provide to a member of the law enforcement community in order to verify the services you are providing to me are
authorized under Maine law.
I have the right to terminate this agreement at any time. This MMMP designation form and designation card is my
property, and any authorized activity conveyed to you through this designation form terminates upon my notice. You
must either dispose of the excess marijuana in your possession on my behalf, or replace me with another qualified
patient. You will have 10 days from the date of notice to return this form to me.
In the event I terminate this agreement and you do not return this designation form to me, I authorize the Maine
Department of Health and Human Services to demand the return of this designation form and card or take other action
to enforce the Rules Governing the Maine Medical Use of Marijuana Program, which includes terminating the caregiver
number that they assigned to you and that you have listed on this designation form.
________________________________
Print name of patient/guardian

_____________________________________
Signature of patient/guardian

___________
Date

_______________________________
Print name of designee

_____________________________________
Signature of designee

___________
Date

Numeric identification assigned by the designee: _____________________

Page 3 of 3

Form 110103 Rev 11/2016


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