Referring Physician or Clinic Information

Referring Physician or Clinic Name:*

Referring Physician or Clinic Phone Number:*

Alternate Phone Number:

Referring Physician or Clinic Fax Number:

Referring Physician or Clinic Email:*

Patient Information

Patient Name:*

Patient Date of Birth (MM/DD/YYYY):*

Patient Phone Number:*

Alternate Phone Number:

Patient Email:*

Patient Consent

By signing this form, I authorize the gathering, use and release of any personal information, including my personal health information (including my current and compliant ACMPR Medical Document and also my medical file that is in your possession) by Patient Services for the purpose of pursuing the potential for coverage of medical cannabis therapy by 3rd party payers (Group Health Benefit Plans, Individual Health Benefit Plans, Government Subsidized Health Plans, Health Spending Accounts, Disability Compensation Plans, etc.) I also authorize Patient Services to communicate with me for the above-mentioned reasons, and I further consent to accept electronic communications from Patient Services that are comprised of information related to my reimbursement request. I recognize that I can remove my consent for any communications by providing notice to Patient Services at any time.

Print Name:*

Today’s Date (MM/DD/YYYY):*

Patient Signature:* (Use your mouse or keypad to write your signature)