PHYSICIAN CERTIFICATION FOR THE USE OF MEDICAL MARIJUANA PURSUANT TO
THE ACT FOR THE HUMANITARIAN MEDICAL USE OF MARIJUANA, SECTIONS 2(N) & 3(B)
THIS DOCUMENT IS A CONFIDENTIAL MEDICAL RECORD AND PROTECTED BY HIPAA AND ALL OTHER
FEDERAL AND STATE LAWS GOVERNING THE CONFIDENTIALITY OF MEDICAL RECORDS
Name of Practice
Physician’s Name
Physician’s Street Address
Physician’s City, State, Zip Code
FOR VERIFICATION CALL:
Physician’s Phone Number
This form is provided by Massachusetts Marijuana Compliance.
This letter is to certify that I am a physician for . The facts that
Patient’s Name
have caused me to certify the use of medicinal marijuana for this patient were made during the course of a bona fide physician patient relationship after a full assessment of the patient’s medical history and condition.
Additionally, this letter verifies that this patient has been diagnosed with
Name of Debilitating Condition
and that in my professional opinion this patient will benefit from the medical use of marijuana, and any possible health risks associated with such medicinal use are outweighed by the benefits to this patient.
Signed: Dated:
Physician’s Signature
Suggested Date of Reexamination:
Patient's License/Identification Number:
Patient's Date of Birth:
Statement of Patient: I will abide the provisions of the Act
Name of Patient
for the Humanitarian Medical Use of Marijuana. I have discussed the risks and benefits associated with the use of marijuana with my physician.
Signed: Dated:
Patient’s
so i had my doctor fill this out and its no good
