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

Cannabis Patient Protection Act

Medical Marijuana

The Cannabis Patient Protection Act – SB 5052 (PDF) integrates the medical market with the regulated recreational market. Under the act, the Department of Health adopted rules for a medical marijuana authorization database, training and certification of medical marijuana consultants, and product compliance. The department was also required to produce several bill-related reports.

Medical Marijuana Authorization Form(s)

 

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.

Medical marijuana authorization form (PDF)630123

Key Information on Medical marijuana:

  • Purpose and intent.
  • Acts not constituting crimes or unprofessional conduct—Health care professionals not subject to penalties or liabilities.
  • Compliance with chapter—Qualifying patients and designated providers not subject to penalties—Law enforcement not subject to liability.
  • Failure to enter into the medical marijuana authorization database—Affirmative defense.
  • Possession of plants, marijuana concentrates, useable marijuana, or marijuana-infused products exceeding lawful amount—Affirmative defense.
  • Medical marijuana, lawful possession—State not liable.
  • Limitations of chapter—Persons under supervision.
  • Crimes—Limitations of chapter.
  • Qualifying patient’s designation of a specific designated provider—Provider’s service as designated provider—Termination—Department may adopt rules.
  • Suitability for organ transplant.
  • Parental rights or residential time—Not to be restricted.
  • State and municipalities—Not subject to liability.
  • Qualifying patients or designated providers—Authorization—Health care professional may include recommendations on amount of marijuana.
  • Health care professionals may authorize medical use of marijuana—Qualifying patients under age eighteen.
  • Medical marijuana authorization database—Recognition cards.
  • Unlawful actions—Criminal penalty.
  • Cooperatives—Qualifying patients or designated providers may form—Requirements—Restrictions on locations—State liquor and cannabis board may adopt rules.
  • Housing unit—No more than fifteen plants may be grown or located—Exception—Civil penalties.
  • Extracting or separating marijuana resin, producing or processing any form of marijuana concentrates or marijuana-infused products—State liquor and cannabis board to adopt rules.
  • Topical, ingestible products—THC concentration.
  • Medical marijuana consultant certificate.
  • Continuing education programs for health care providers.
Frequently asked questions about the authorization form:
  • What is a valid written authorization?
  • What is tamper-resistant paper?
  • Does the authorizing practitioner have to personally fill out the form?
  • What if the authorizing practitioner has terrible handwriting?
  • May I verify an authorization by calling the Department of Health?
  • May I use a website or email address instead of a phone number for verification?
  • What if the patient doesn’t want their address or medical condition on the form?
  • Is my Washington medical marijuana (cannabis) authorization valid in other states?
  • Doesn’t including the patient’s medical condition violate HIPAA?
  • What is a valid written authorization?
    • Authorizations must be written on tamper-resistant paper (see below). They must include an original signature by the healthcare provider, a date and a statement that says in the healthcare provider’s professional opinion the patient may benefit from the medical use of marijuana. All authorizations must be on the Department of Health form dated June 2015 in order to be valid. Any other form of recommendation or authorization is invalid.
  • What is tamper-resistant paper?
    • “Tamper-resistant paper” means paper that meets one or more of the following industry-recognized features:
      • To prevent copying of the paper;
      • To prevent the erasure or modification of information on the paper; or
      • Designed to prevent the use of counterfeit authorization.
      • Letter size tamper-resistant paper can be purchased by the healthcare practitioner from the same vendors that supply prescription materials. However, because it is not a prescription, medical marijuana authorizations do not require the Pharmacy Board logo on it.
  • Does the authorizing practitioner have to personally fill out the form?
    • Yes. The authorizing practitioner is ultimately responsible for the form. The authorizing practitioner must personally fill out and sign the “Attestation of Healthcare Practitioner” and the optional section regarding additional plants, if that section is used.
    • The authorizing practitioner’s staff members may fill out the “Patient and Designated Provider and Authorizing Healthcare Practitioner Information” sections. The authorizing practitioner may pre-print the information in the “Authorizing Healthcare Practitioner Information” section. Neither the patient nor the designated provider may fill out any portion of the form other than signing under the attestation.
    • In addition, the healthcare practitioner’s office is responsible for verifying that the patient is a Washington state resident.
  • What if the authorizing practitioner has terrible handwriting?
    • The form is the authorizing practitioner’s responsibility. All information on the form must be legible. Information that is illegible or false renders the form invalid.
  • May I verify an authorization by calling the Department of Health?
    • No, The Department doesn’t maintain a list of authorizations. Do NOT send your form to the Department of Health.
  • May I use a website or email address instead of a telephone number for verification?
    • No. The law requires a telephone number for the authorizing practitioner where the authorization can be verified during normal business hours. You may include a website or email address in addition to the telephone number.
  • What if the patient doesn’t want their address or medical condition(s) on the form?
    • All the information must be included. If boxes are left empty the form is invalid.
  • Is my Washington medical marijuana authorization valid in other states?
    • Some states may recognize a medical marijuana authorization from Washington. Medical marijuana patients from Washington should check with other states before traveling, and should comply with the laws in those states. Healthcare practitioner authorizations, ID cards and other documentation from other states aren’t valid in Washington.
  • Doesn’t including the patient’s medical condition violate HIPAA?
    • No. HIPAA is violated only when a healthcare practitioner, insurance company or healthcare clearinghouse (such as a billing service) provides protected information to a third party. It’s not a violation for the authorizing practitioner to give the patient his or her own information. It’s not a violation for the patient to provide his or her own information to anyone.

Instructions for healthcare practitioner authorizing the use of marijuana:

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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