SECTION 1: Qualifying Patient Information

Medical Provider Written Certification:

For questions regarding this program, please contact the following:
Department of Health and Human Services Maine Center for Disease Control and Prevention Maine Medical Use of Marijuana Program
286 Water Street
11 State House Station Augusta, ME 04333-0011
Tel: (207) 287-8016 Fax: (207) 287-2671 TTY Users: Dial 711 (Maine Relay)

Email: dhhs.mmmp@maine.gov
Website: www.mainepublichealth.gov/mmm

SECTION 3A: Cultivating Caregiver Information

SECTION 3B: Non Cultivating Caregiver Information

SECTION 4: Dispensary Information

SECTION 5: 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 a copy of my Maine Medical Use of Marijuana Program identification card/MMMP certification and my original designation 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 medical use of marijuana certification issued by my 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 Maine provider certification and 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 MMMP designation form and designation card 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 and card 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.