Get Practitioner Written Certification Form - Rhode Island ...

Filling out the Practitioner Written Certification Form for Rhode Island is an essential step in the medical marijuana registration process. This guide will walk you through each section of the form to ensure compliance with the Rhode Island Medical Marijuana Act while making the process straightforward and clear.

Follow the steps to accurately complete your form online.

1. Press the ‘Get Form’ button to access the form and open it in your document editor.
2. Begin by entering the patient information at the top of the form, including their full name, date of birth, and phone number. Make sure to follow the date format: Birth Month, Birth Day, Birth Year.
3. Next, move to the practitioner's section. Provide the practitioner's full name, license number, and address, including any apartment or suite details in the first line, followed by the street address, city, state, and zip code.
4. Indicate the qualifying debilitating medical condition by checking the appropriate box or boxes from the provided list. Be sure to include details, such as 'severe debilitating chronic pain', if applicable.
5. In the comments section, include any additional information or context related to the patient's medical condition if necessary.
6. Enter the practitioner's email address in the format Username@domain (e.g., applicant@isp.com).
7. The attending practitioner must certify their relationship with the patient by signing and dating the form. This acknowledges that they have assessed the patient's medical history and believe medical marijuana could benefit the patient.
8. If the patient is eligible for hospice care, the practitioner must sign in the designated area. Otherwise, proceed to the bottom of the form.
9. Once all sections are completed and verified for accuracy, save your changes. You may then download, print, or share the form as needed.

Complete your forms online today to ensure compliance and facilitate the registration process.