Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the document and open it in your preferred online editor.
2. Fill in the qualifying patient information. Provide the first name, middle name, last name, home address, apartment or suite number, city, state, ZIP code, date of birth, and gender of the patient. Ensure all information is typed or printed clearly.
3. Complete the health care professional information section. Enter your first name, middle name, last name, office address, suite number, city, state, ZIP code, office telephone number, email address, Illinois license number, and Illinois controlled substances license number.
4. Indicate the length of time the patient has been under your care by specifying the number of years and months. Also, record the date of the in-person medical examination related to this certification.
5. In the debilitating medical condition section, select all applicable diagnoses by checking the corresponding boxes. This section requires you to confirm the patient's diagnosed conditions under treatment.
6. Review and complete the attestation statements. As a health care professional, you will affirm that you have established a bona-fide relationship with the patient, conducted an in-person examination within the last 90 days, and reviewed the patient’s medical history.
7. Provide your signature in the designated area, ensuring no stamps are used, and enter the date of your signature. This certifies that all provided information is accurate.
8. After completing the form, save your changes. You may download, print, or share the document as required. Ensure to upload the form in PDF format with the qualifying patient application online.

Complete your documents online today to ensure accurate submission and adherence to the guidelines.