Medical Marijuana Program Physician Recommendation Order Form

Patient Application

Instructions:

Before starting your application, please gather all the required information and documents you will need to complete it. Incomplete applications cannot be saved and returned to later.

Required items include:

1. A healthcare practitioner recommendation with a date of issuance within 2 years of the application submission date OR Self-Certification for individuals 21 and older*
2. Social Security Number or a copy of a sworn affidavit stating lack of one*
3. One (1) current face photo, "2x2"*
4. One (1) copy of DC DMV REAL ID* OR
- One (1) proof of DC residency and*
- One (1) copy of government-issued photo ID*
5. Caregiver Application (Optional)
6. Reduced fee proof of income documentation (Optional)

Upon submission, you will be sent a confirmation of receipt email. If your application needs additional documentation, you will receive an email with the necessary documents requested.

After all necessary documents are reviewed you will receive an email with a digital letter and a physical card will be mailed to your residence. Fees have been waived for new and renewal applications received by August 18, 2022.

To ensure prompt receipt, please add our email addressmedicalcannabis@dc.gov to your safe senders list, address book, or contact list.

Program details are available 24/7 at abra.dc.gov. Phone and email inquiries are responded to Monday-Friday from 8:30 a.m.-4:00 p.m.

* Indicates a required field

Patient Information

Application Type

First Name

Middle Initial

Last Name

Suffix

DC DMV Real ID

SSN

Enter SSN
Reenter SSN

upload sworn affidavit document below.

Date of Birth

Street

Apt/ Suite

City

State

Zip

Phone

Reenter Email

Recommendation Information

Certification Type

Recommendation Number

Recommending Healthcare Professional First Name

Recommending Healthcare Professional Last Name

Required Documents

Face Photo

Government ID

Proof of Residency #1

DC DMV Real ID

Required Documents--Reduced Fee Applicants Only

Do you meet the requirements for a reduced application fee?

Current Medicaid or DC Alliance card
OR
Proof total gross income <= 200% of the Federal Poverty Level #1 of 2
Proof total gross income <= 200% of the Federal Poverty Level #2 of 2

Required Documents--Applicants with No SSN Only

Sworn Affidavit

Optional--Applicants Designating a Caregiver Only

Caregiver Application

Intended Fee Payment Method

Payment Method

Signature

By typing my name and the date below, I verify that I am the person identified above and that all information provided is true to the best of my knowledge. I am acknowledging that I am aware of District of Columbia Medical cannabis Laws and Regulations and stated terms and conditions

Terms and Conditions

Limitation of Liability

The District of Columbia shall not be liable to the registrant, its employees, agents, business invitees, licensees, customers, clients, family members or guests for any damage, injury, accident, loss, compensation or claim, based on, arising out of or resulting from registrant's participation in the District of Columbia's medical marijuana program, including but not limited to the following: arrest and seizure of persons and/or property, prosecution pursuant to federal laws by federal prosecutors, interruption in registrant's ability to operate its medical marijuana cultivation center and/or dispensary; any fire, robbery, theft, mysterious disappearance or any other casualty; the actions of any other registrants or persons within the cultivation center and/or dispensary. This Limitation of Liability provision shall survive expiration or the earlier termination of this registration if such registration is granted.

Federal Prosecution

The United States Congress has determined that marijuana is a controlled substance and has placed marijuana in Schedule I of the Controlled Substance Act. Growing, distributing, and possessing marijuana in any capacity, other than as a part of a federally authorized research program, is a violation of federal laws. The District of Columbia's law authorizing the District's medical marijuana program will not excuse any registrant from any violation of the federal laws governing marijuana or authorize any registrant to violate federal laws.

I hereby certify that all of the information provided on this application is true and accurate to the best of my knowledge. I acknowledge receipt and advisement of the notices above, and I agree to and accept the limitation of liability against the District. I assume any and all risk or liability that may result under the District of Columbia or federal laws arising from the possession, use, or cultivation, administration, or dispensing of medical marijuana. I understand that the medical marijuana laws and enforcement thereof of the District of Columbia and the Federal government are subject to change at any time. I sign this attestation willingly and without reservation and am fully aware of its meaning and effect.

I agree to terms and conditions

I have read and agree to the self certification requirements

First and Last Name

Date

Government of the District of ColumbiaAlcoholic Beverage Regulation Administration
Medical Cannabis Program