R9-17-202. Applying for a Registry Identification Card for a Qualifying Patient or a Designated Caregiver 2017-02-11T17:24:34+00:00

A. Except for a qualifying patient who is under 18 years of age, a qualifying patient is not required to have a designated caregiver.

B. A qualifying patient may have only one designated caregiver at any given time.

C. Except for a qualifying patient who is under 18 years of age, if the information submitted for a qualifying patient complies with A.R.S. Title 36, Chapter 28.1 and this Chapter but the information for the qualifying patient’s designated caregiver does not comply A.R.S. Title 36, Chapter 28.1 and this Chapter, the Department shall issue the registry identification card for the qualifying patient separate from issuing a registry identification card for the qualifying patient’s designated caregiver.

D. If the Department issues a registry identification card to a qualifying patient under subsection (C), the Department shall continue the process for issuing or denying the qualifying patient’s designated caregiver’s registry identification card.

E. The Department shall not issue a designated caregiver’s registry identification card before the Department issues the designated caregiver’s qualifying patient’s registry identification card.

F. Except as provided in subsection (G), to apply for a registry identification card, a qualifying patient shall submit to the Department the following:

1. An application in a Department-provided format that includes:

a. The qualifying patient’s:

i. First name; middle initial, if applicable; last name; and suffix, if applicable;

ii. Date of birth; and

iii. Gender;

b. Except as provided in subsection (F)(1)(i), the qualifying patient’s residence address and mailing address:

c. The county where the qualifying patient resides;

d. The qualifying patient’s e-mail address;

e. The identifying number on the applicable card or document in subsection (F)(2)(a) through (F)(2)(e);

f. The name, address, and telephone number of the physician providing the written certification for medical marijuana for the qualifying patient;

g. Whether the qualifying patient is requesting authorization for cultivating marijuana plants for the qualifying patient’s medical use because the qualifying patient believes that the qualifying patient resides at least 25 miles from the nearest operating dispensary;

h. If the qualifying patient is requesting authorization for cultivating marijuana plants, whether the qualifying patient is designating the qualifying patient’s designated caregiver to cultivate marijuana plants for the qualifying patient’s medical use;

i. If the qualifying patient is homeless, an address where the qualifying patient can receive mail;

j. Whether the qualifying patient would like notification of any clinical studies needing human subjects for research on the medical use of marijuana;

k. An attestation that the information provided in the application is true and correct; and

l. The signature of the qualifying patient and date the qualifying patient signed;

2. A copy of the qualifying patient’s:

a. Arizona driver’s license issued on or after October 1, 1996;

b. Arizona identification card issued on or after October 1, 1996;

c. Arizona registry identification card;

d. Photograph page in the qualifying patient’s U.S. passport; or

e. Arizona driver’s license or identification card issued before October 1, 1996 and one of the following for the qualifying patient:

i. Birth certificate verifying U.S. citizenship,

ii. U.S. Certificate of Naturalization, or

iii. U.S. Certificate of Citizenship;

3. A current photograph of the qualifying patient;

4. A statement in a Department-provided format signed by the qualifying patient pledging not to divert marijuana to any individual or entity who is not allowed to possess marijuana pursuant to A.R.S. Title 36, Chapter 28.1;

5. A physician’s written certification in a Department-provided format dated within 90 calendar days before the submission of the qualifying patient’s application that includes:

a. The physician’s:

i. Name,

ii. License number including an identification of the physician license type,

iii. Office address on file with the physician’s licensing board,

iv. Telephone number on file with the physician’s licensing board, and

v. E-mail address;

b. The qualifying patient’s name and date of birth;

c. A statement that the physician has made or confirmed a diagnosis of a debilitating medical condition as defined in A.R.S. § 36-2801 for the qualifying patient;

d. An identification of one or more of the debilitating medical conditions in R9-17-201 as the qualifying patient’s specific debilitating medical condition;

e. If the debilitating medical condition identified in subsection (F)(5)(d) is a condition in:

i. R9-17-201(9) through R9-17-201(13), the underlying chronic or debilitating disease or medical condition; or

ii. R9-17-201(14), the debilitating medical condition;

f. A statement, initialed by the physician, that the physician:

i. Has established a medical record for the qualifying patient; and

ii. Is maintaining the qualifying patient’s medical record as required in A.R.S. § 12-2297;

g. A statement, initialed by the physician, that the physician has conducted an in-person physical examination of the qualifying patient within the previous 90 calendar days appropriate to the qualifying patient’s presenting symptoms and the qualifying patient’s debilitating medical condition diagnosed or confirmed by the physician;

h. The date the physician conducted the in-person physical examination of the qualifying patient;

i. A statement, initialed by the physician, that the physician reviewed the qualifying patient’s:

i. Medical records including medical records from other treating physicians from the previous 12 months,

ii. Response to conventional medications and medical therapies, and

iii. Profile on the Arizona Board of Pharmacy Controlled Substances Prescription Monitoring Program database;

j. A statement, initialed by the physician, that the physician has explained the potential risks and benefits of the medical use of marijuana to the qualifying patient;

k. A statement, initialed by the physician, that, in the physician’s professional opinion, the qualifying patient is likely to receive therapeutic or palliative benefit from the qualifying patient’s medical use of marijuana to treat or alleviate the qualifying patient’s debilitating medical condition;

l. A statement, initialed by the physician, that, if the physician has referred a qualifying patient to a dispensary, the physician has disclosed to the qualifying patient any personal or professional relationship the physician has with the dispensary;

m. An attestation that the information provided in the written certification is true and correct; and

n. The physician’s signature and the date the physician signed;

6. If the qualifying patient is designating a caregiver, the following in a Department-provided format:

a. The designated caregiver’s first name; middle initial, if applicable; last name; and suffix, if applicable;

b. The designated caregiver’s date of birth;

c. The designated caregiver’s residence address and mailing address;

d. The county where the designated caregiver resides;

e. The identifying number on the applicable card or document in subsection (F)(6)(i)(i) through (F)(6)(i)(v);

f. One of the following:

i. A statement that the designated caregiver does not currently hold a valid registry identification card; or

ii. The assigned registry identification number for the designated caregiver for each valid registry identification card currently held by the designated caregiver;

g. An attestation signed and dated by the designated caregiver that the designated caregiver has not been convicted of an excluded felony offense as defined in A.R.S. § 36-2801;

h. A statement in a Department-provided format signed by the designated caregiver:

i. Agreeing to assist the qualifying patient with the medical use of marijuana; and

ii. Pledging not to divert marijuana to any individual or entity who is not allowed to possess marijuana pursuant to A.R.S. Title 36, Chapter 28.1;

i. A copy of the designated caregiver’s:

i Arizona driver’s license issued on or after October 1, 1996;

ii. Arizona identification card issued on or after October 1, 1996;

iii. Arizona registry identification card;

iv. Photograph page in the designated caregiver’s U.S. passport; or

v. Arizona driver’s license or identification card issued before October 1, 1996 and one of the following for the designated caregiver:

(1) Birth certificate verifying U.S. citizenship,

(2) U.S. Certificate of Naturalization, or

(3) U.S. Certificate of Citizenship;

j. A current photograph of the designated caregiver; and

k. For the Department’s criminal records check authorized in A.R.S. § 36-2804.05:

i. The designated caregiver’s fingerprints on a fingerprint card that includes:

(1) The designated caregiver’s first name; middle initial, if applicable; and last name;

(2) The designated caregiver’s signature;

(3) If different from the designated caregiver, the signature of the individual physically rolling the designated caregiver’s fingerprints;

(4) The designated caregiver’s address;

(5) If applicable, the designated caregiver’s surname before marriage and any names previously used by the designated caregiver;

(6) The designated caregiver’s date of birth;

(7) The designated caregiver’s social security number;

(8) The designated caregiver’s citizenship status;

(9) The designated caregiver’s gender;

(10) The designated caregiver’s race;

(11) The designated caregiver’s height;

(12) The designated caregiver’s weight;

(13) The designated caregiver’s hair color;

(14) The designated caregiver’s eye color; and

(15) The designated caregiver’s place of birth; or

ii. If the designated caregiver’s fingerprints and information required in subsection (F)(6)(k)(i) were submitted to the Department as part of an application for a designated caregiver or a dispensary agent registry identification card within the previous six months, the registry identification number on the registry identification card issued to the designated caregiver as a result of the application; and

7. The applicable fees in R9-17-102 for applying for:

a. A qualifying patient registry identification card; and

b. If applicable, a designated caregiver registry identification card.

G. To apply for a registry identification card for a qualifying patient who is under 18 years of age, the qualifying patient’s custodial parent or legal guardian responsible for health care decisions for the qualifying patient shall submit to the Department the following:

1. An application in a Department-provided format that includes:

a. The qualifying patient’s:

i. First name; middle initial, if applicable; last name; and suffix, if applicable;

ii. Date of birth; and

iii. Gender;

b. The qualifying patient’s residence address and mailing address;

c. The county where the qualifying patient resides;

d. The qualifying patient’s custodial parent’s or legal guardian’s first name; middle initial, if applicable; last name; and suffix, if applicable;

e. The identifying number on the applicable card or document in subsection (G)(6)(a) through (G)(6)(e);

f. The qualifying patient’s custodial parent’s or legal guardian’s residence address and mailing address;

g. The county where the qualifying patient’s custodial parent or legal guardian resides;

h. The qualifying patient’s custodial parent’s or legal guardian’s e-mail address;

i. The name, address, and telephone number of a physician who has a physician-patient relationship with the qualifying patient and is providing the written certification for medical marijuana for the qualifying patient;

j. The name, address, and telephone number of a second physician who has conducted a comprehensive review of the patient’s medical record maintained by other treating physicians, and is providing written certification for medical marijuana for the qualifying patient;

k. The qualifying patient’s custodial parent’s or legal guardian’s date of birth;

l. Whether the qualifying patient’s custodial parent or legal guardian is requesting authorization for medical marijuana cultivation because the qualifying patient’s custodial parent or legal guardian believes that the qualifying patient resides at least 25 miles from the nearest operating dispensary;

m. Whether the qualifying patient’s custodial parent or legal guardian would like notification of any clinical studies needing human subjects for research on the medical use of marijuana;

n. Whether the individual submitting the application on behalf of the qualifying patient under 18 years of age is the qualifying patient’s custodial parent or legal guardian;

o. An attestation that the information provided in the application is true and correct; and

p. The signature of the qualifying patient’s custodial parent or legal guardian and the date the qualifying patient’s custodial parent or legal guardian signed;

2. A current photograph of the:

a. Qualifying patient, and

b. Qualifying patient’s custodial parent or legal guardian serving as the qualifying patient’s designated caregiver;

3. An attestation signed and dated by the qualifying patient’s custodial parent or legal guardian that the qualifying patient’s custodial parent or legal guardian has not been convicted of an excluded felony offense as defined in A.R.S. § 36-2801;

4. One of the following:

a. A statement that the qualifying patient’s custodial parent or legal guardian does not currently hold a valid registry identification card; or

b. The assigned registry identification number for the qualifying patient’s custodial parent or legal guardian for each valid registry identification card currently held by the qualifying patient’s custodial parent or legal guardian;

5. A statement in a Department-provided format signed by the qualifying patient’s custodial parent or legal guardian who is serving as the qualifying patient’s designated caregiver:

a. Allowing the qualifying patient’s medical use of marijuana;

b. Agreeing to assist the qualifying patient with the medical use of marijuana; and

c. Pledging not to divert marijuana to any individual or entity who is not allowed to possess marijuana pursuant to A.R.S. Title 36, Chapter 28.1;

6. A copy of one of the following for the qualifying patient’s custodial parent or legal guardian:

a. Arizona driver’s license issued on or after October 1, 1996;

b. Arizona identification card issued on or after October 1, 1996;

c. Arizona registry identification card;

d. Photograph page in the qualifying patient’s custodial parent or legal guardian U.S. passport; or

e. Arizona driver’s license or identification card issued before October 1, 1996 and one of the following for the qualifying patient’s custodial parent or legal guardian:

i. Birth certificate verifying U.S. citizenship,

ii. U. S. Certificate of Naturalization, or

iii. U. S. Certificate of Citizenship;

7. If the individual submitting the application on behalf of a qualifying patient is the qualifying patient’s legal guardian, a copy of documentation establishing the individual as the qualifying patient’s legal guardian;

8. For the Department’s criminal records check authorized in A.R.S. § 36-2804.05:

a. The qualifying patient’s custodial parent or legal guardian’s fingerprints on a fingerprint card that includes:

i. The qualifying patient’s custodial parent or legal guardian’s first name; middle initial, if applicable; and last name;

ii. The qualifying patient’s custodial parent or legal guardian’s signature;

iii. If different from the qualifying patient’s custodial parent or legal guardian, the signature of the individual physically rolling the qualifying patient’s custodial parent’s or legal guardian’s fingerprints;

iv. The qualifying patient’s custodial parent’s or legal guardian’s address;

v. If applicable, the qualifying patient’s custodial parent’s or legal guardian’s surname before marriage and any names previously used by the qualifying patient’s custodial parent or legal guardian;

vi. The qualifying patient’s custodial parent’s or legal guardian’s date of birth;

vii. The qualifying patient’s custodial parent’s or legal guardian’s social security number;

viii. The qualifying patient’s custodial parent’s or legal guardian’s citizenship status;

ix. The qualifying patient’s custodial parent’s or legal guardian’s gender;

x. The qualifying patient’s custodial parent’s or legal guardian’s race;

xi. The qualifying patient’s custodial parent’s or legal guardian’s height;

xii. The qualifying patient’s custodial parent’s or legal guardian’s weight;

xiii. The qualifying patient’s custodial parent’s or legal guardian’s hair color;

xiv. The qualifying patient’s custodial parent’s or legal guardian’s eye color; and

xv. The qualifying patient’s custodial parent’s or legal guardian’s place of birth; or

b. If the qualifying patient’s custodial parent’s or legal guardian’s fingerprints and information required in subsection (G)(8)(a) were submitted to the Department as part of an application for a designated caregiver or a dispensary agent registry identification card within the previous six months, the registry identification number on the registry identification card issued to the qualifying patient’s custodial parent or legal guardian as a result of the application;

9. A written certification from the physician in subsection (G)(1)(i) and a separate written certification from the physician in (G)(1)(j) in a Department-provided format dated within 90 calendar days before the submission of the qualifying patient’s application that includes:

a. The physician’s:

i. Name,

ii. License number including an identification of the physician license type,

iii. Office address on file with the physician’s licensing board,

iv. Telephone number on file with the physician’s licensing board, and

v. E-mail address;

b. The qualifying patient’s name and date of birth;

c. An identification of one or more of the debilitating medical conditions in R9-17-201 as the qualifying patient’s specific debilitating medical condition;

d. If the debilitating medical condition identified in subsection (G)(9)(c) is a condition in:

i. R9-17-201(9) through R9-17-201(13), the underlying chronic or debilitating disease or medical condition; or

ii. R9-17-201(14), the debilitating medical condition;

e. For the physician listed in subsection (G)(1)(i):

i. A statement that the physician has made or confirmed a diagnosis of a debilitating medical condition as defined in A.R.S. § 36-2801 for the qualifying patient;

ii. A statement, initialed by the physician, that the physician:

(1) Has established a medical record for the qualifying patient; and

(2) Is maintaining the qualifying patient’s medical record as required in A.R.S. § 12-2297;

iii. A statement, initialed by the physician, that the physician has conducted an in-person physical examination of the qualifying patient within the previous 90 calendar days appropriate to the qualifying patient’s presenting symptoms and the qualifying patient’s debilitating medical condition diagnosed or confirmed by the physician;

iv. The date the physician conducted the in-person physical examination of the qualifying patient;

v. A statement, initialed by the physician, that the physician reviewed the qualifying patient’s:

(1) Medical records including medical records from other treating physicians from the previous 12 months,

(2) Response to conventional medications and medical therapies, and

(3) Profile on the Arizona Board of Pharmacy Controlled Substances Prescription Monitoring Program database; and

vi. A statement, initialed by the physician, that the physician has explained the potential risks and benefits of the use of medical marijuana to the qualifying patient’s custodial parent or legal guardian responsible for the health care decisions for the qualifying patient;

f. For the physician listed in subsection (G)(1)(j), a statement, initialed by the physician, that the physician conducted a comprehensive review of the qualifying patient’s medical records from other treating physicians;

g. A statement, initialed by the physician, that, in the physician’s professional opinion, the qualifying patient is likely to receive therapeutic or palliative benefit from the qualifying patient’s medical use of marijuana to treat or alleviate the qualifying patient’s debilitating medical condition;

h. A statement, initialed by the physician, that, if the physician has referred the qualifying patient’s custodial parent or legal guardian to a dispensary, the physician has disclosed to the qualifying patient any personal or professional relationship the physician has with the dispensary;

i. An attestation that the information provided in the written certification is true and correct; and

j. The physician’s signature and the date the physician signed; and

10. The applicable fees in R9-17-102 for applying for a:

a. Qualifying patient registry identification card, and

b. Designated caregiver registry identification card.

H. For purposes of this Article, “25 miles” includes the area contained within a circle that extends for 25 miles in all directions from a specific location.

I. For purposes of this Article, “residence address” when used in conjunction with a qualifying patient means:

1. The street address including town or city and zip code assigned by a local jurisdiction; or

2. For property that does not have a street address assigned by a local jurisdiction, the legal description of the property on the title documents recorded by the assessor of the county in which the property is located.

This is an unofficial version of the Medical Marijuana Program rules. At this time, ADHS does not anticipate making substantive changes to these rules before they are filed with the Office of the Secretary of State. However, technical, organizational, and grammatical changes may be made. The official copy will be posted on www.azsos.gov when filed.