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How to fill out the Attending Physician Statement Form online
Completing the Attending Physician Statement Form is an essential step in registering for the Oregon Medical Marijuana Program. This guide provides clear, step-by-step instructions to assist you in filling out the form accurately and efficiently online.
Follow the steps to complete the form online.
- Click ‘Get Form’ button to obtain the Attending Physician Statement Form and open it in the editing interface.
- Begin by filling in the patient information section. Enter the patient's name, date of birth, mailing address, telephone number, and the city, state, and ZIP code.
- Next, complete the physician information section. Provide your name, mailing address, telephone number, and the city, state, and ZIP code.
- In the physician’s statement section, indicate the patient’s debilitating medical condition by checking the appropriate boxes from the provided list of conditions.
- If applicable, check any additional symptoms that the patient is experiencing related to their medical condition in the designated section.
- Add any necessary comments or notes regarding the patient's condition and the potential benefit of medical marijuana in the comments field.
- Review the declaration statement confirming your licensure and responsibility for the patient's care. Provide your signature and the date.
- Finally, save your changes to the form, download a copy if needed, or print the completed document to share it with the relevant authorities.
Complete your Attending Physician Statement Form online today to ensure timely registration for the Oregon Medical Marijuana Program.
“The Attending Physician Statement is a summary of your health condition, written from a doctor or medical facility that either has treated or is currently treating someone that is seeking life insurance,” explains Paya Schlass, Customer Success Manager at Haven Life.
Fill Attending Physician Statement Form
INSTRUCTIONS TO PHYSICIAN FOR COMPLETING FORM CA-20, ATTENDING PHYSICIAN'S REPORT. Complete the entire form and return to the employee. 1. Patient Information. Name. This form is to be completed without expense to the State of Indiana. To Be Completed By The Attending Physician. The following information is needed to document the patient's inability to work. Name of Patient. DOB. I authorize my healthcare or rehabilitation provider to disclose my personal information, including my medical and health information and including. Name: If yes, please state relationship. Are you related to the patient?
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