Medical Marijuana Authorization Form(s) for Marijuana Patients, Washington State


Cannabis Patient Protection Act :
 Medical Marijuana

Authorization Form

The medical marijuana authorization form is ONLY to be completed by the authorizing healthcare practitioner. Please read the following instructions fully before downloading the form.

 

In order to be valid, the medical marijuana authorization form must be:

  • Written on the form linked above for all new authorizations beginning July 1, 2016.
  • Printed single-sided on 8.5 x 11 tamper-resistant paper for both pages as defined in RCW 69.51A.010. Note: The form doesn’t require the Pharmacy Commission logo, but the form is still valid if it’s used.

Fully completed by the authorizing healthcare practitioner with the patient and the patient’s designated provider, if any*:

  • Every box must be filled in unless it is described as “Optional.”
  • Mark N/A if a designated provider isn’t identified.
  • The healthcare practitioner must list their office phone number for verification. Note: The medical marijuana consultant isn’t required to verify the authorization unless they have concerns about its validity.
  • The patient and designated provider (if any*) must each have their own form completed with the information fields for both the patient and designated provider; and each will sign their own form under the attestation.

Form expiration date

  • Authorizations expire after one year for adult patients and six months for patients under the age of 18.
  • The authorizing healthcare practitioner may indicate an earlier expiration date, but the law doesn’t require that.

*Designated provider (this is NOT the healthcare practitioner)

A designated provider is someone that the medical marijuana patient authorizes to purchase their marijuana product for or to grow the marijuana for the patient. They must be named on the patient’s medical marijuana authorization form and have a completed form also printed on the tamper-resistant paper.

The patient and designated provider, if any, must each obtain an individual authorization from the authorizing healthcare professional. It’s not sufficient for the designated provider to possess a copy of the patient’s authorization.

The designated provider must sign the form under the attestation.

Record keeping

  • The healthcare practitioner must keep a copy of the two-page form in the patient’s medical record.
  • The patient must keep the original – Do not send a copy to the Department of Health. The department doesn’t maintain a list of authorizations.
  • A certified medical marijuana consultant is available in medically endorsed stores to put the authorization form information into the voluntary authorization database and create a recognition card. The store does not keep a copy of the authorization form.

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