R9-17-204. Renewing a Qualifying Patient’s or Designated Caregiver’s Registry Identification Card 2017-02-11T17:24:34+00:00

A. Except for a qualifying patient who is under 18 years of age, to renew a qualifying patient’s registry identification card, the qualifying patient shall submit the following to the Department at least 30 calendar days before the expiration date of the qualifying patient’s registry identification card:

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

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

b. The qualifying patient’s date of birth;

c. Except as provided in subsection (A)(1)(j), the qualifying patient’s residence address and mailing address;

d. The county where the qualifying patient resides;

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

f. The registry identification number on the qualifying patient’s current registry identification card;

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

h. 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;

i. 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;

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

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

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

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

2. If the qualifying patient’s name in subsection (A)(1)(a) is not the same name as on the qualifying patient’s current registry identification card, one of the following with the qualifying patient’s new name:

a. An Arizona driver’s license,

b. An Arizona identification card, or

c. The photograph page in the qualifying patient’s U.S. passport;

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 renewal 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 (A)(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 the 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 or if the qualifying patient’s designated caregiver’s registry identification card has the same expiration date as the qualifying patient’s registry identification card, 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. If the qualifying patient is renewing the designated caregiver’s registry identification card, the registry identification number on the designated caregiver’s registry identification card associated with the qualifying patient;

f. If the qualifying patient is designated an individual not previously designated as the qualifying patient’s caregiver, the identification number on and 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;

g. A current photograph of the designated caregiver;

h. 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;

i. 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;

j. 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; 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 (A)(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;

7. If the qualifying patient’s designated caregiver’s registry identification card has the same expiration date as the qualifying patient’s registry identification card and the designated caregiver’s name in subsection (A)(6)(a) is not the same name as on the designated caregiver’s current registry identification card, one of the following with the designated caregiver’s new name:

a. An Arizona driver’s license,

b. An Arizona identification card, or

c. The photograph page in the designated caregiver’s U.S. passport; and

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

a. Renew a qualifying patient’s registry identification card; and

b. If applicable, issue or renew a designated caregiver’s registry identification card.

B. To renew 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; and

ii. Date of birth;

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

c. The county where the qualifying patient resides;

d. The registry identification number on the qualifying patient’s current registry identification card;

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

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 registry identification number on the qualifying patient’s custodial parent’s or legal guardian’s current registry identification card;

j. 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;

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

l. Whether the qualifying patient’s custodial parent or legal guardian is requesting approval for cultivating marijuana plants for the qualifying patient’s medical use 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. 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:

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

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

iii. 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;

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. If the qualifying patient’s custodial parent’s or legal guardian’s name in subsection (B)(1)(e) is not the same name as on the qualifying patient’s custodial parent’s or legal guardian’s current registry identification card, one of the following with the custodial parent’s or legal guardian’s new name:

a. An Arizona driver’s license,

b. An Arizona identification card, or

c. The photograph page in the qualifying patient’s custodial parent’s or legal guardian’s U.S. passport; and

3. A current photograph of the qualifying patient;

4. A written certification from the physician in subsection (B)(1)(j) and a separate written certification from the physician in subsection (B)(1)(k) in a Department-provided format dated within 90 calendar days before the submission of the qualifying patient’s renewal 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 (B)(4)(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 (B)(1)(j):

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 (B)(1)(k), 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’s custodial parent or legal guardian 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

5. A current photograph of the qualifying patient’s custodial parent or legal guardian;

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

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

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

ii. The qualifying patient’s custodial parent’s 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 (B)(6)(a) were submitted as part of an application for a designated caregiver or a dispensary agent to the Department within the previous six months, the registry identification number on the registry identification card issued to the patient’s custodial parent or legal guardian serving as the qualifying patient’s designated caregiver as a result of the application; and

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

a. Qualifying patient’s registry identification card, and

b. Designated caregiver’s registry identification card.

C. Except as provided in subsection (A)(6), to renew a qualifying patient’s designated caregiver’s registry identification card, the qualifying patient shall submit to the Department, at least 30 calendar days before the expiration date of the designated caregiver’s registry identification card, the following:

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

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

b. The registry identification number on the qualifying patient’s current registry identification card;

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

d. The designated caregiver’s date of birth;

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

f. The county where the designated caregiver resides;

g. The registry identification number on the designated caregiver’s current registry identification card;

h. A current photograph of the designated caregiver;

i. 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 person who is not allowed to possess marijuana pursuant to A.R.S. Title 36, Chapter 28.1; and

j. 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 (C)(1)(j)(i) were submitted as part of an application for a designated caregiver or a dispensary agent registry identification card to the Department 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;

2. If the designated caregiver’s name in subsection (C)(1)(a) is not the same name as on the designated caregiver’s current registry identification card, one of the following with the designated caregiver’s new name:

a. An Arizona driver’s license,

b. An Arizona identification card, or

c. The photograph page in the principal officer’s or board member’s U.S. passport; and

3. The applicable fee in R9-17-102 for renewing a designated caregiver’s registry identification card.

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.

%d bloggers like this: