STATE OF MAINE

DEPARTMENT OF HEALTH AND HUMAN SERVICES

DIVISION OF LICENSING AND REGULATORY SERVICES

Medical Use of Marijuana Program

Designation Form

(For patients to designate a caregiver or dispensary)

 

SECTION 1: Patient Information

Legal Name:      

Date of Birth:      

Driver’s License No.:       

Telephone No.: (     )     -     

Home Address:      

City:      

State:      

Zip:      

County:      

Expiration date of Provider Certification:       

 

SECTION 2: Cultivation Authorization                                                                                  May only allocate up to 6 plants

 

     

# of  plants I will grow

     

# of  plants my caregiver will grow

     

# of plants  my dispensary will grow

     

Visiting qualifying patient (must be included as 1 of the 5 patients allowed per caregiver)                                                                           

May Designate caregiver or dispensary-Not both

Total # (Not to exceed 6)

     

 

SECTION 3: Medical Marijuana Transportation

How will the medical marijuana be transported? (Check all that apply)

 I will pick up the medical marijuana from my designated caregiver/dispensary.

 The designated caregiver/dispensary will deliver my medical marijuana to me.

 Name of designated caregiver. (See Caregiver information section 4)

 

For questions regarding this program and/or application, please contact the following:

Department of Health and Human Services

Licensing and Regulatory Services

Maine Medical Use of Marijuana Program

41 Anthony Ave

11 State House Station

Augusta, ME 04333-0011

 

Tel: (207) 287-4325                          Fax: (207) 287-2671

Toll Free: 1-800-791-4080              TTY users call Maine relay 711

Email: medmarijuana.dhhs@maine.gov

Website: http://www.maine.gov/dhhs/dlrs/mmm/index.shtml

 

 

 

 

 

 

 

 

SECTION 4: Caregiver Designation (Complete only if designating a Caregiver)

Legal Name:      

Telephone No.: (     )     -     

Street Address:      

City:      

State:      

Zip:      

County:      

Caregiver MMMP Registration # assigned to this patient:

(if cultivating for the patient and registration is required)        

Primary caregiver registration required; EXCEPTIONS, Section 5.4

 

o   Section 5.4.1:  A primary caregiver designated to cultivate for a qualifying patient if that qualifying patient Is a member of the household of that primary caregiver;

o   Section 5.4.2: Two primary caregivers who are also both qualifying patients, if those primary caregivers are members of the same household and assist one another with cultivation;

o   Section 5.4.3: A primary caregiver who cultivates for a qualifying patient if that qualifying patient is a member of the family of that primary caregiver (see 22MRSA 2423-A (3) (C)

 

 

 

 

SECTION 5: Dispensary Designation (Complete only if designating a Dispensary)

Name of Dispensary:      

City:      

Telephone No.: (     )     -     

Name of Dispensary Representative:      

Name of Non Grow Caregiver, if any, who may pick up marijuana for me at the dispensary:       

 

 

 

SECTION 6: Expiration and Renewal of Designation

Expiration:

This designation form expires on (month/day/year)     .

Renewal:

The patient is required to complete a new designation form annually in order to renew the designation of a caregiver or dispensary.

 

 

 

 

 

 

 

 

 

 

 

SECTION 7: Patient Rights and Responsibilities

·         My provider has certified that I have a condition that entitles me to participate in the Maine Medical Use of Marijuana Program until     ______________________. I have provided you with either a copy of that certification or a copy of my Maine Medical Use of Marijuana Program identification card as proof that I am authorized to participate in the program. I have also provided you a copy of my Maine issued driver license or other Maine issued photo identification card as proof of my identity.

      If I am visiting from another state, I have provided you with a copy of the MMMP provider certification form completed by my provider in the state of      _______________________ as evidence that I live in a state that authorizes marijuana for medical purposes and have a debilitating condition authorized under Maine law. I have also provided you with a copy of my photographic identification card or driver’s license from my home jurisdiction. As a visiting qualifying patient, I agree to abide by all terms and conditions of the Maine Medical Use of Marijuana Program.

 

You are hereby authorized to share this caregiver designation form and any copies of documents that I am required to provide to a member of the law enforcement community in order to verify the services you are providing to me are authorized under Maine law.

 

I have the right to terminate this agreement at any time. This caregiver designation form is my property, and any authorized activity conveyed to you through this designation form terminates upon my notice. You must either dispose of the excess marijuana in your possession on my behalf, or replace me with another qualified patient. You will have 10 days from the date of notice to return this form to me.

 

In the event I terminate this agreement and you do not return this designation form to me, I authorize the Maine Department of Health and Human Services to demand the return of this designation form or take other action to enforce the Rules Governing the Maine Medical Use of Marijuana Program, which includes terminating the caregiver number that they assigned to you and that you have listed on this designation form.

 

 

_______________________________________  _____________________________________  ____________________

Print name of patient/guardian                                                Signature of patient/guardian                                  Date

 

 

_______________________________________  _____________________________________  ____________________

Print name of caregiver                                                                Signature of caregiver                                                  Date

 

 

_______________________________________  _____________________________________  ____________________

Print name of dispensary representative             Signature of dispensary representative               Date