Get Mt Marijuana Program Physician Satement Form

The Mt Marijuana Program Physician Statement Form is a crucial document for registered cardholder applicants with a debilitating medical condition. This guide will provide step-by-step instructions on how to accurately fill out this form online, ensuring a smooth submission process.

Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to access the Mt Marijuana Program Physician Statement Form and open it in the editor.
2. Begin by entering the patient's full name and date of birth. Ensure that this information matches with the data on file with the Montana Board of Medical Examiners.
3. Fill in the physician's name and Montana license number, along with their office address and mailing address, including city, state, and ZIP code.
4. Provide the business email and telephone number of the physician. If any information has changed, indicate whether it is new information that needs to be updated in the Marijuana System.
5. Select one or two options to confirm the relationship between the physician and the patient by initialing the appropriate statement.
6. Circle the medical condition(s) for which marijuana is being recommended. You may choose more than one condition from the provided list.
7. In a statement or attached documentation, specify the debilitating medical condition, describe why it is debilitating, and mention prior treatments and their ineffectiveness.
8. List any restrictions to the patient’s activities due to the use of marijuana.
9. Indicate the appropriate time period for the use of marijuana, ensuring it does not exceed one year.
10. In signing the form, the physician certifies their qualifications and conditions regarding the patient's use of marijuana. Ensure all required statements are checked and signed.
11. Finally, save any changes made to the form, and ensure it is downloaded, printed, or shared as necessary. Remember that only the original form is accepted.

Complete your forms online today to ensure a smooth application process.