Illinois Medical Cannabis Pilot Program

Application for Registry Identification Card for Qualifying Patients

INSTRUCTIONS:

• Qualifying patients whose last name begins with the letters A though L may apply from September 2, 2014 through October 31, 2014.

• Qualifying patients whose last name begins with the letters M though Z may apply from November 1, 2014 through December 31, 2014.

To qualify for a patient registry identification card, a qualifying patient must:

• be a resident of the state of Illinois at the time of application and remain a resident during participation in the program;

• have a qualifying debilitating medical condition;

• have a signed physician certification for the use of medical cannabis;

• complete the fingerprint-based background check and not have been convicted of an excluded offense (a felony under the Illinois Controlled Substances Act, Cannabis Control Act or Methamphetamine Control and Community Protection Act, or similar provisions in a local ordinance or other jurisdiction), unless the Department waives such a conviction(s); and

• be at least 18 years of age.

A complete application must include all of the following:

• A signed and completed application form.

• Proof of residency.

• Proof of identity of the qualifying patient.

• Proof of age of the qualifying patient.

• Photograph of the qualifying patient (Contact the Department’s Division of Medical Cannabis if a photograph would be in violation of or contradictory to the qualifying patient or designated caregiver’s religious convictions).

• Physician written certification or appropriate documentation for veterans receiving medical care at a U.S. Department of Veterans Affairs facility; your physician must mail in this form.

• Designated caregiver information, if applicable.

• Copy of the fingerprint consent form.

• Excluded offense waiver, if applicable.

• Selection of medical cannabis dispensary or zone.

• Application fee.

If mailing, this application must be submitted to:

Illinois Department of Public Health
Division of Medical Cannabis
535 West Jefferson Street
Springfield, Illinois 62761-0001

Following are the steps in the qualification process:  

First and foremost, you must have a medical condition that qualifies you for the use of medical marijuana under Illinois state statutes for the legal use of medical cannabis.
If you suffer from any of the conditions below, you could benefit from the use of medical marijuana:

• Acquired Immunodeficiency Syndrome (AIDS)
• Agitation of Alzheimer’s disease
• Amyotrophic Lateral Sclerosis (ALS)
• Arnold-Chiari malformation and Syringomelia
• Cachexia/wasting syndrome
• Cancer
• Causalgia
• Chronic Inflammatory Demyelinating Polyneuropathy
• Crohn’s disease
• CRPS (Complex Regional Pain Syndromes Type II)
• Dystonia
• Fibromyalgia (severe)
• Fibrous dysplasia
• Glaucoma
• Hepatitis C
• Human Immunodeficiency Virus (HIV)
• Hydrocephalus
• Interstitial Cystitis
• Lupus
• Multiple Sclerosis
• Muscular dystrophy
• Myasthenia Gravis
• Myoclonus
• Nail-patella syndrome
• Neurofibromatosis
• Parkinson’s disease
• Post-concussion syndrome
• RSD (Complex Regional Pain Syndromes Type I)
• Residual limb pain
• Rheumatoid arthritis (RA)
• Seizures, including those characteristic of epilepsy (Starting January 1, 2015)
• Sjogren’s syndrome
• Spinal cord disease, including, but not limited to, arachnoiditis, Tarlov cysts, hydromyelia, syringomyelia
• Spinal cord injury
• Spinocerebellar Ataxia (SCA)
• Tourette’s syndrome
• Traumatic brain injury (TBI)

Step One:  Medical Record Collection

The first step in the medical marijuana application process is extensive documentation of your medical condition. Without current and verifiable medical records, our physicians will be unable to certify your condition under Illinois law.

Although there are conditions where a patient will qualify for the Compassionate Use of Medical Cannabis Pilot Program Act without the necessity of full documentation, the Illinois Marijuana Clinics require that all your records are current within the last  year to document your qualifying condition.   If you prefer that we handle your medical record collection, you must complete the medical release form and fax or mail it to our office so that we may request your medical records from your current  treatment providers.

If you already have your medical records, you can fax or email them to us, whichever is more convenient.
•Fax records to 312.488.2666   Please note that faxed records are limited to no more than 25 pages.

•eMail records to:   info@ilmarijuanaclinics.com

Step Two: Physician Review

Upon receipt of your medical records, our physicians thoroughly review the records to determine if you qualify for the Compassionate Use of Medical Cannabis Pilot Program Act. If additional documents are required for the review, a staff member will contact you and let you know which documents are needed for our records. If you qualify for the program, we will call you to schedule an appointment with one of our physicians.

Step 3: Certification Appointment

At your certification appointment, our physicians will talk with you about your qualification for certification of a medical condition that may qualify you for the Compassionate Use of Medical Cannabis Pilot Program Act. By law, our physicians must only discuss your qualification for the program. After review and approval, qualified patients will receive a signed Physician Certification Form that will allow them to apply to the state for an Illinois Medical Marijuana Registry Card. In order to receive the Physician Certification Form, patients must present a valid Illinois ID, such as a Illinois Drivers Licence or Illinois ID Card, along with the physician visit fee. Please note that insurance companies do not cover medical marijuana consultations or the state’s medical marijuana application fee.

Step 4: Application for Medical Marijuana Registry Card  

In order to obtain your Medical Marijuana Registry, you must send the following information to the Illinois Department of Health Services:  •Signed and dated State Medical Marijuana Application Form  •Physician’s Certification  •Caregiver Attestation (if applicable)  •Photo ID

NOTE: Many all of these rules may change when the Compassionate Use of Medical Cannabis Pilot Program Act passes in Illinois.

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