HEALTH CARE PROFESSIONAL VERIFICATION FORM

State of Vermont
Marijuana Registry
103 South Main Street
Waterbury, Vermont 05671-2101
www.dps.vermont.gov
Department of Public Safety
[phone]
[fax]
[email]
802-241-5115
802-241-5230
[email protected]
HEALTH CARE PROFESSIONAL VERIFICATION FORM
INSTRUCTIONS: This form must be completed by the patient applicant’s health care professional. This form must be
signed within the last 6 months to be acceptable. Failure to submit this completed form will render the patient’s
application incomplete. The definitions listed below are provided to assist the health care professional completing this
form.
DEFINITIONS:
“Bona fide health care professional-patient relationship” means:
A treating or consulting relationship of not less than six months duration, in the course of which a health care
professional has completed a full assessment of the registered patient’s medical history and current medical condition,
including a personal physical examination. The six-month requirement shall not apply if a patient has been diagnosed
with:
A) a terminal illness;
B) cancer with distant metastases; or
C) acquired immune deficiency syndrome.
A patient applicant may be approved, notwithstanding the six-month requirement, if the debilitating medical condition is of
recent or sudden onset and a previous health care professional was unable to verify the nature of the disease and its
symptoms.
“Health care professional” means an individual who is:
A) licensed as a physician or osteopathic physician under 26 V.S.A Chapter 23 or Chapter 33;
B) licensed as a naturopathic physician under 26 V.S.A. Chapter 81, who has a special license endorsement authorizing
the individual to prescribe, dispense, and administer prescription medicines to the extent that a diagnosis provided
by a naturopath under this chapter is within the scope of his or her practice;
C) certified as a physician’s assistant under 26 V.S.A. Chapter 31; or
D) licensed as an advanced practice registered nurse under 26 V.S.A. Chapter 28.
This definition includes professionally licensed individuals under substantially equivalent provisions in New
Hampshire, Massachusetts, or New York, except for naturopaths.
“Debilitating medical condition” means a disease, medical condition, or its treatment, that is chronic, debilitating, and
reasonable medical efforts have been made over a reasonable amount of time without success to relieve the symptoms,
for the following diagnoses:
A) cancer, acquired immune deficiency syndrome, positive status for human immunodeficiency virus, multiple
sclerosis; or
B) any other diagnoses that produces chronic, debilitating and severe, persistent and one or more of the following
intractable symptoms: cachexia or wasting syndrome, severe pain, severe nausea, or seizures.
A patient applicant without a “debilitating medical condition” is not eligible for a Marijuana Registry identification card.
THIS FORM MUST BE SUBMITTED WITH A PATIENT APPLICATION!
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State of Vermont
Marijuana Registry
Department of Public Safety
HEALTH CARE PROFESSIONAL VERIFICATION FORM
The Marijuana Registry will contact the health care professional completing this form for the purposes of confirming the
accuracy of the information contained on this form.
ALL SECTIONS OF THIS FORM MUST BE COMPLETED
THIS FORM MUST BE SUBMITTED WITH A PATIENT APPLICATION!
PATIENT APPLICANT’S INFORMATION (Please print legibly)
Full Legal Name: Last ______________________________ First __________________________________ M.I. ________
Date of Birth: ______________________________
Telephone Number: _____________________________________
HEALTH CARE PROFESSIONAL INFORMATION (Please print legibly)
Full Legal Name: Last ___________________________________ First ________________________________ M.I. _____
Office Mailing Address: ________________________________________________________________________________
City, State, Zip: ____________________________________________ Telephone Number: _________________________
HEALTH CARE PROFESSIONAL LICENSE INFORMATION:
License Number: ______________________________
Issuing State (circle one):
VT
NH
MA
NY
LICENSURE CATEGORY
Doctor of Medicine
Physician Assistant
Osteopathic Physician
Advanced Practice Registered Nurse
Naturopathic Physician
VERIFICATION OF A DEBILITATING MEDICAL CONDITION
I am not treating or consulting the patient applicant for a debilitating medical condition as defined.
I am treating or consulting the patient applicant for cancer.
I am treating or consulting the patient applicant for acquired immune deficiency syndrome.
I am treating or consulting the patient applicant for human immunodeficiency virus.
I am treating or consulting the patient applicant for multiple sclerosis.
I am treating or consulting the patient applicant for a disease, medical condition, or its treatment that is chronic,
debilitating, and produces severe, persistent and one or more of the following intractable symptoms: cachexia (wasting
syndrome), severe pain, severe nausea; or seizures. This selection REQUIRES the following information:
(A) Indicate specific diagnosis:
_____________________________________________________________________
(B) Indicate specific symptom (circle all that apply):
cachexia
severe pain
severe nausea
seizures
-----------------------------------------------------------------------------------------------------------------------------------------------------OFFICE USE ONLY – NOTES:
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_____________________________________________________________________________________________
State of Vermont
Marijuana Registry
Department of Public Safety
BONA FIDE HEALTH CARE PROFESSIONAL-PATIENT RELATIONSHIP STATEMENT
I HAVE a bona fide health care professional-patient relationship with the patient.
I do NOT have a bona fide health care professional-patient relationship with the patient, and the medical condition IS of
recent or sudden onset and the patient has not had a previous health care professional who is able to verify the nature of the
disease and its symptoms.
I do NOT have a bona fide health care professional-patient relationship with the patient, and the medical condition IS NOT of
recent or sudden onset and a previous health care professional was able to verify the nature of the disease and its symptoms.
ATTESTATION OF INFORMATION
I certify:
1) I am a health care professional;
A) licensed as a physician or osteopathic physician under 26 V.S.A Chapter 23 or Chapter 33;
B) licensed as a naturopathic physician under 26 V.S.A Chapter 81, who has a special license endorsement authorizing the
individual to prescribe, dispense, and administer prescription medicines to the extent that a diagnosis provided by a
naturopath under this chapter is within the scope of his or her practice;
C) certified as a physician’s assistant under 26 V.S.A Chapter 31; or
D) licensed as an advanced practice registered nurse under 26 V.S.A Chapter 28,
in good standing with the regulating state, and that the facts stated above are true and accurate to the best of my knowledge and
belief.
2) Reasonable medical efforts have been made over a reasonable amount of time without success to relieve the patient’s
symptoms.
3) I understand, notwithstanding any law to the contrary, a person who knowingly provides false information on this application
may be guilty of perjury and imprisoned for not more than one year or fined not more than $1,000.00 or both. This penalty
shall be in addition to any other penalties that may apply.
This form is to verify the nature of the disease and its symptoms; this is not a prescription or medical recommendation for
the use of marijuana.
Health Care Professional’s Signature: _______________________________________ Date: _____________________
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
I hereby authorize the health care professional named on this form to release my protected medical information to the
Marijuana Registry to verify and confirm the accuracy of the information contained within this form. I authorize the named health
care professional to:
•
•
•
Disclose the nature, symptoms, and duration of the medical condition identified on this form for the purpose of
determining that it meets the legal definition of a debilitating medical condition on page 1 of this form;
Disclose whether the named health care professional and I have a bona fide health care professional-patient relationship,
as defined by law and on page 1 of this form;
Confirm the accuracy of the information contained in this form.
I understand that any information released to the Registry will be used solely to confirm the accuracy of the information
contained in this form. While the information will no longer be covered by the HIPAA Privacy Rule, Vermont law requires the
Registry to keep all information confidential, except for the prosecution of false swearing. I understand this authorization is valid
for one year from the date the Registry receives this form, unless a written communication revoking this authorization or a new
authorization is received by the Registry. I understand that I have the right to revoke this authorization at any time by notifying
both the health care professional named on this form and to the Registry in writing.
Patient Applicant Signature REQUIRED: _______________________________________________ Date: ____________
If the patient applicant is under the age of 18 or has a court appointed guardian the section below must be completed:
Parent or Guardian Signature: __________________________________________________________ Date: ____________
THIS FORM MUST BE SUBMITTED WITH A PATIENT APPLICATION!
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