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    MMR Change of Address

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    cwadotorg
    This form is for patients registered in the Colorado Medical Marijuana Registry to report a change of address, care-giver, or both. It requires the patient to provide their name, new address, social security number, date of birth, phone number and gender. If designating a new care-giver, that person's name, address, date of birth, and phone number are also required. The completed, signed and notarized form along with a copy of valid photo IDs for the patient and care-giver must be mailed to the Colorado Department of Public Health and Environment. A warning is given that marijuana possession remains illegal under federal law.

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    Attribution Non-Commercial (BY-NC)
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    MMR Change of Address

    Uploaded by

    cwadotorg
    48 views1 page
    This form is for patients registered in the Colorado Medical Marijuana Registry to report a change of address, care-giver, or both. It requires the patient to provide their name, new address, social security number, date of birth, phone number and gender. If designating a new care-giver, that person's name, address, date of birth, and phone number are also required. The completed, signed and notarized form along with a copy of valid photo IDs for the patient and care-giver must be mailed to the Colorado Department of Public Health and Environment. A warning is given that marijuana possession remains illegal under federal law.

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    This form is for patients registered in the Colorado Medical Marijuana Registry to report a change of address, care-giver, or both. It requires the patient to provide their name, new address, social security number, date of birth, phone number and gender. If designating a new care-giver, that person's name, address, date of birth, and phone number are also required. The completed, signed and notarized form along with a copy of valid photo IDs for the patient and care-giver must be mailed to the Colorado Department of Public Health and Environment. A warning is given that marijuana possession remains illegal under federal law.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    48 views1 page

    MMR Change of Address

    Uploaded by

    cwadotorg
    This form is for patients registered in the Colorado Medical Marijuana Registry to report a change of address, care-giver, or both. It requires the patient to provide their name, new address, social security number, date of birth, phone number and gender. If designating a new care-giver, that person's name, address, date of birth, and phone number are also required. The completed, signed and notarized form along with a copy of valid photo IDs for the patient and care-giver must be mailed to the Colorado Department of Public Health and Environment. A warning is given that marijuana possession remains illegal under federal law.

    Copyright:

    Attribution Non-Commercial (BY-NC)
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    Medical Marijuana Registry

    CHANGE OF ADDRESS OR CARE-GIVER


    INSTRUCTIONS:
    When there has been a change in the name, address, or care-giver of a patient who has qualified for a registry identifica-
    tion card, that patient must notifiy the state health agency of any such change within ten (10) days. Please complete all
    required information in blue ink, sign, and date in front of notary, and have notarized. Mail this form with a legible copy
    of the patient’s and care-giver’s photo ID to:
    Colorado Department of Public Health and Environment
    Medical Marijuana Registry or MMR, HSVRD-MMP-A1
    4300 Cherry Creek Drive South
    Denver, Colorado 80246-1530
    Incomplete forms or forms without ID, will be returned to the applicant. You may contact the Registry at 303-692-2184.
    Last Name (as it appears on your ID) First Name (as it appears on your ID) Middle Initial
    APPLICANT

    Mailing Address City County State Zip Code

    Social Security Number Date of Birth Telephone Number Gender

    Male

    Alternate Number Female

    You may choose to designate a caregiver, although you do not have to. A caregiver is defined as “a person, other than
    the patient and the patient’s physician, who is eighteen years of age or older and has significant responsibility for
    managing the well-being of a patient who has a debilitating medical condition.”

    NONE (SKIP CARE-GIVER SECTION)


    Last Name (as it appears on your ID) First Name (as it appears on your ID) Middle Initial
    CARE-GIVER

    Mailing Address City State Zip Code

    Date of Birth Telephone Number Alternate Number

    WARNING! THE USE, POSSESSION, DISTRIBUTION, AND MANUFACTURE OF MARIJUANA REMAINS A FEDERAL
    CRIME IN COLORADO, AND POSSESSION OF A REGISTRATION CARD PROVIDES NO PROTECTION WHATSOEVER
    AGAINST FEDERAL CRIMINAL PROSECUTION.
    I hereby certify that the above information is correct and complete.
    Applicant’s Signature: Date Signed:

    X
    The Applicant’s Signature has been subscribed and affirmed before me in the county of ____________________________, State of Colorado,

    this __________ day of _____________________, 20_____.

    ______________________________________________________
    (Notary’s Official Signature)

    ______________________________________________________
    (Commission expiration date)
    AFFIX NOTARY SEAL
    Rev. August 2009

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