Get Physician Written Certification Form - State Of Illinois - Www2 Illinois

This guide provides a clear and supportive walkthrough for completing the Physician Written Certification Form required for the Illinois Medical Cannabis Pilot Program. It is important for physicians to accurately and thoroughly fill out this form to ensure compliance with state regulations.

Follow the steps to fill out the Physician Written Certification Form online.

1. Press the ‘Get Form’ button to acquire the Physician Written Certification Form and open it in your preferred editing tool.
2. Fill in the qualifying patient information, including first name, middle name, last name, home address, date of birth, and gender. Ensure that all information is typed or written clearly and accurately.
3. Complete the physician information section. Include the name of the hospital, university, or practice, and provide your first name, middle name, last name, office address, office telephone number, email address, Illinois physician license number, DEA registration number, and specialty.
4. Indicate the length of time the patient has been under your care, and include the date of the in-person medical examination related to this certification.
5. In the debilitating medical condition section, check all applicable conditions the patient has been diagnosed with, and if necessary, indicate any underlying chronic or debilitating disease.
6. Provide comments if there are additional pertinent details that may assist in assessing the patient's application. If no comments are applicable, cross through this section.
7. In the attestations section, initial each statement confirming the physician-patient relationship, the conduct of a recent examination, the review of medical history, and the explanation of potential risks and benefits of cannabis use.
8. At the bottom of the form, certify your status as a licensed physician and provide your signature and the date of signature. Stamps are not accepted.
9. Once the form is filled out, save your changes, and download or print the document. Remember, this form must be mailed to the Illinois Department of Public Health and should not be given to the patient.

Complete the necessary documentation online to assist patients in the Illinois Medical Cannabis Pilot Program.