Ariz. Admin. Code § R9-17-204 - Renewing a Qualifying Patient's or Designated Caregiver's Registry Identification Card
A. Except for a
qualifying patient who is under 18 years of age, to renew a qualifying
patient's registry identification card, the qualifying patient shall submit the
following to the Department at least 30 calendar days before the expiration
date of the qualifying patient's registry identification card:
1. An application in a Department-provided
format that includes:
a. The qualifying
patient's first name; middle initial, if applicable; last name; and suffix, if
applicable;
b. The qualifying
patient's date of birth;
c. Except
as provided in subsection (A)(1)(j), the qualifying patient's Arizona residence
address and Arizona mailing address;
d. The county where the qualifying patient
resides;
e. The qualifying
patient's e-mail address;
f. The
registry identification number on the qualifying patient's current registry
identification card;
g. The name,
address, and telephone number of the physician providing the written
certification for medical marijuana for the qualifying patient;
h. Whether the qualifying patient is
requesting authorization for cultivating marijuana plants for the qualifying
patient's medical use because the qualifying patient believes that the
qualifying patient resides at least 25 miles from the nearest operating
dispensary;
i. If the qualifying
patient is requesting authorization for cultivating marijuana plants, whether
the qualifying patient is designating the qualifying patient's designated
caregiver to cultivate marijuana plants for the qualifying patient's medical
use;
j. If the qualifying patient
is homeless, an address where the qualifying patient can receive
mail;
k. Whether the qualifying
patient would like notification of any clinical studies needing human subjects
for research on the medical use of marijuana;
l. An attestation that the information
provided in the application is true and correct; and
m. The signature of the qualifying patient
and the date the qualifying patient signed;
2. If the qualifying patient's name in
subsection (A)(1)(a) is not the same name as on the qualifying patient's
current registry identification card, one of the following with the qualifying
patient's new name:
a. An Arizona driver's
license,
b. An Arizona
identification card, or
c. The
photograph page in the qualifying patient's U.S. passport or a U.S. passport
card;
3. A current
photograph of the qualifying patient;
4. A statement in a Department-provided
format signed by the qualifying patient pledging not to divert marijuana to any
individual who or entity that is not allowed to possess marijuana pursuant to
A.R.S. Title 36, Chapter 28.1;
5. A
physician's written certification in a Department-provided format dated within
90 calendar days before the submission of the qualifying patient's renewal
application that includes:
a. The physician's:
i. Name,
ii. License number including an
identification of the physician license type,
iii. Office address on file with the
physician's licensing board,
iv.
Telephone number on file with the physician's licensing board, and
v. E-mail address;
b. The qualifying patient's name and date of
birth;
c. A statement that the
physician has made or confirmed a diagnosis of a debilitating medical condition
as defined in A.R.S. §
36-2801 for the qualifying
patient;
d. An identification of
one or more of the debilitating medical conditions in
R9-17-201 as the qualifying
patient's specific debilitating medical condition;
e. If the debilitating medical condition
identified in subsection (A)(5)(d) is a condition in:
i.
R9-17-201(9) through
(13), the underlying chronic or debilitating
disease or medical condition; or
ii.
R9-17-201(14), the
debilitating medical condition;
f. A statement, initialed by the physician,
that the physician:
i. Has established a
medical record for the qualifying patient, and
ii. Is maintaining the qualifying patient's
medical record as required in A.R.S. §
12-2297;
g. A statement, initialed by the physician,
that the physician has conducted a physical examination of the qualifying
patient within the previous 90 calendar days appropriate to the qualifying
patient's presenting symptoms and the qualifying patient's debilitating medical
condition diagnosed or confirmed by the physician;
h. The date the physician conducted the
physical examination of the qualifying patient;
i. A statement, initialed by the physician,
that the physician reviewed the qualifying patient's:
i. Medical records including medical records
from other treating physicians from the previous 12 months,
ii. Response to conventional medications and
medical therapies, and
iii. Profile
on the Arizona Board of Pharmacy Controlled Substances Prescription Monitoring
Program database;
j. A
statement, initialed by the physician, that the physician has explained the
potential risks and benefits of the medical use of marijuana to the qualifying
patient;
k. A statement, initialed
by the physician, that, in the physician's professional opinion, the qualifying
patient is likely to receive therapeutic or palliative benefit from the
qualifying patient's medical use of marijuana to treat or alleviate the
qualifying patient's debilitating medical condition;
l. A statement, initialed by the physician,
that, if the physician has referred the qualifying patient to a dispensary, the
physician has disclosed to the qualifying patient any personal or professional
relationship the physician has with the dispensary;
m. A statement, initialed by the physician,
that the physician has provided information to the qualifying patient, if the
qualifying patient is female, that warns about:
i. The potential dangers to a fetus caused by
smoking or ingesting marijuana while pregnant or to an infant while
breastfeeding, and
ii. The risk of
being reported to the Department of Child Safety during pregnancy or at the
birth of the child by persons who are required to report;
n. An attestation that the information
provided in the written certification is true and correct; and
o. The physician's signature and the date the
physician signed;
6. If
the qualifying patient is designating a caregiver or if the qualifying
patient's designated caregiver's registry identification card has the same
expiration date as the qualifying patient's registry identification card, the
following in a Department-provided format:
a.
The designated caregiver's first name; middle initial, if applicable; last
name; and suffix, if applicable;
b.
The designated caregiver's date of birth;
c. The designated caregiver's Arizona
residence address and Arizona mailing address;
d. The county where the designated caregiver
resides;
e. If the qualifying
patient is renewing the designated caregiver's registry identification card,
the registry identification number on the designated caregiver's registry
identification card associated with the qualifying patient;
f. If the qualifying patient is designating
an individual not previously designated as the qualifying patient's designated
care-giver, the identification number on and a copy of the designated
caregiver's:
i. Arizona driver's license
issued on or after October 1, 1996;
ii. Arizona identification card issued on or
after October 1, 1996;
iii. Arizona
registry identification card;
iv.
Photograph page in the designated caregiver's U. S. passport or a U.S. passport
card; or
v. Arizona driver's
license or identification card issued before October 1, 1996 and one of the
following for the designated caregiver:
(1)
Birth certificate verifying U.S. citizenship,
(2) U. S. Certificate of Naturalization,
or
(3) U. S. Certificate of
Citizenship;
g.
A current photograph of the designated caregiver;
h. An attestation signed and dated by the
designated caregiver that the designated caregiver:
i. Has not been convicted of an excluded
felony offense as defined in A.R.S. §
36-2801, or
ii. Is deemed to not have been convicted of
an excluded felony offense through holding a valid level I fingerprint
clearance card issued according to A.R.S. §
41-1758.07;
i. A statement in a Department-provided
format signed by the designated caregiver:
i.
Agreeing to assist the qualifying patient with the medical use of marijuana;
and
ii. Pledging not to divert
marijuana to any individual who or entity that is not allowed to possess
marijuana pursuant to A.R.S. Title 36, Chapter 28.1; and
j. For the Department's criminal records
check authorized in A.R.S. §
36-2804.05:
i. The designated caregiver's fingerprints on
a fingerprint card that includes:
(1) The
designated caregiver's first name; middle initial, if applicable; and last
name;
(2) The designated
caregiver's signature;
(3) If
different from the designated caregiver, the signature of the individual
physically rolling the designated care-giver's fingerprints;
(4) The designated caregiver's
address;
(5) If applicable, the
designated caregiver's surname before marriage and any names previously used by
the designated caregiver;
(6) The
designated caregiver's date of birth;
(7) The designated caregiver's Social
Security number;
(8) The designated
caregiver's citizenship status;
(9)
The designated caregiver's gender;
(10) The designated caregiver's
race;
(11) The designated
caregiver's height;
(12) The
designated caregiver's weight;
(13)
The designated caregiver's hair color;
(14) The designated caregiver's eye color;
and
(15) The designated caregiver's
place of birth; or
ii. If
the designated caregiver's fingerprints and information required in subsection
(A)(6)(j)(i) were submitted to the Department as part of an application for a
designated caregiver registry identification card, dispensary agent registry
identification card, or laboratory agent registry identification card within
the previous six months, the registry identification number on the registry
identification card issued to the designated caregiver as a result of the
application; or
iii. Documentation
that the designated caregiver has a valid level I fingerprint clearance card
issued according to A.R.S. §
41-1758.07;
7. If the qualifying
patient's designated caregiver's registry identification card has the same
expiration date as the qualifying patient's registry identification card and
the designated caregiver's name in subsection (A)(6)(a) is not the same name as
on the designated caregiver's current registry identification card, one of the
following with the designated caregiver's new name:
a. An Arizona driver's license,
b. An Arizona identification card,
or
c. The photograph page in the
designated caregiver's U.S. passport or a U.S. passport card; and
8. The applicable fees in
R9-17-102 for applying to:
a. Renew a qualifying patient's registry
identification card; and
b. If
applicable, issue or renew a designated caregiver's registry identification
card.
B. To
renew a registry identification card for a qualifying patient who is under 18
years of age, the qualifying patient's custodial parent or legal guardian
responsible for health care decisions for the qualifying patient shall submit
to the Department the following:
1. An
application in a Department-provided format that includes:
a. The qualifying patient's:
i. First name; middle initial, if applicable;
last name; and suffix, if applicable; and
ii. Date of birth;
b. The qualifying patient's Arizona residence
address and Arizona mailing address;
c. The county where the qualifying patient
resides;
d. The registry
identification number on the qualifying patient's current registry
identification card;
e. The
qualifying patient's custodial parent's or legal guardian's first name; middle
initial, if applicable; last name; and suffix, if applicable;
f. The qualifying patient's custodial
parent's or legal guardian's Arizona residence address and Arizona mailing
address;
g. The county where the
qualifying patient's custodial parent or legal guardian resides;
h. The qualifying patient's custodial
parent's or legal guardian's e-mail address;
i. The registry identification number on the
qualifying patient's custodial parent's or legal guardian's current registry
identification card;
j. The name,
address, and telephone number of a physician who has a physician-patient
relationship with the qualifying patient and is providing the written
certification for medical marijuana for the qualifying patient;
k. The name, address, and telephone number of
a second physician who has conducted a comprehensive review of the qualifying
patient's medical record maintained by other treating physicians, and is
providing a written certification for medical marijuana for the qualifying
patient;
l. Whether the qualifying
patient's custodial parent or legal guardian is requesting approval for
cultivating marijuana plants for the qualifying patient's medical use because
the qualifying patient's custodial parent or legal guardian believes that the
qualifying patient resides at least 25 miles from the nearest operating
dispensary;
m. Whether the
qualifying patient's custodial parent or legal guardian would like notification
of any clinical studies needing human subjects for research on the medical use
of marijuana;
n. A statement in a
Department-provided format signed by the qualifying patient's custodial parent
or legal guardian who is serving as the qualifying patient's designated
caregiver:
i. Allowing the qualifying
patient's medical use of marijuana;
ii. Agreeing to assist the qualifying patient
with the medical use of marijuana; and
iii. Pledging not to divert marijuana to any
individual who or entity that is not allowed to possess marijuana pursuant to
A.R.S. Title 36, Chapter 28.1;
o. An attestation that the information
provided in the application is true and correct; and
p. The signature of the qualifying patient's
custodial parent or legal guardian and the date the qualifying patient's
custodial parent or legal guardian signed;
2. If the qualifying patient's custodial
parent's or legal guardian's name in subsection (B)(1)(e) is not the same name
as on the qualifying patient's custodial parent's or legal guardian's current
registry identification card, one of the following with the custodial parent's
or legal guardian's new name:
a. An Arizona
driver's license,
b. An Arizona
identification card, or
c. The
photograph page in the qualifying patient's custodial parent's or legal
guardian's U.S. passport or a U.S. passport card;
3. A current photograph of the qualifying
patient;
4. A written certification
from the physician in subsection (B)(1)(j) and a separate written certification
from the physician in subsection (B)(1)(k) in a Department-provided format
dated within 90 calendar days before the submission of the qualifying patient's
renewal application that includes:
a. The
physician's:
i. Name,
ii. License number including an
identification of the physician license type,
iii. Office address on file with the
physician's licensing board,
iv.
Telephone number on file with the physician's licensing board, and
v. E-mail address;
b. The qualifying patient's name and date of
birth;
c. An identification of one
or more of the debilitating medical conditions in
R9-17-201 as the qualifying
patient's specific debilitating medical condition;
d. If the debilitating medical condition
identified in subsection (B)(4)(c) is a condition in:
i.
R9-17-201(9) through
(13), the underlying chronic or debilitating
disease or medical condition; or
ii.
R9-17-201(14), the
debilitating medical condition;
e. For the physician listed in subsection
(B)(1)(j):
i. A statement that the physician
has made or confirmed a diagnosis of a debilitating medical condition as
defined in A.R.S. §
36-2801 for the qualifying
patient;
ii. A statement, initialed
by the physician, that the physician:
(1) Has
established a medical record for the qualifying patient, and
(2) Is maintaining the qualifying patient's
medical record as required in A.R.S. §
12-2297;
iii. A statement, initialed by the physician,
that the physician has conducted a physical examination of the qualifying
patient within the previous 90 calendar days appropriate to the qualifying
patient's presenting symptoms and the qualifying patient's debilitating medical
condition diagnosed or confirmed by the physician;
iv. The date the physician conducted the
physical examination of the qualifying patient;
v. A statement, initialed by the physician,
that the physician reviewed the qualifying patient's:
(1) Medical records including medical records
from other treating physicians from the previous 12 months,
(2) Response to conventional medications and
medical therapies, and
(3) Profile
on the Arizona Board of Pharmacy Controlled Substances Prescription Monitoring
Program database;
vi. A
statement, initialed by the physician, that the physician has explained the
potential risks and benefits of the use of medical marijuana to the qualifying
patient's custodial parent or legal guardian responsible for health care
decisions for the qualifying patient; and
vii. A statement, initialed by the physician,
that the physician has provided information to the qualifying patient's
custodial parent or legal guardian responsible for health care decisions for
the qualifying patient, if the qualifying patient is female, that warns about:
(1) The potential dangers to a fetus caused
by smoking or ingesting marijuana while pregnant or to an infant while
breastfeeding, and
(2) The risk of
being reported to the Department of Child Safety during pregnancy or at the
birth of the child by persons who are required to report;
f. For the physician
listed in subsection (B)(1)(k), a statement, initialed by the physician, that
the physician conducted a comprehensive review of the qualifying patient's
medical records from other treating physicians;
g. A statement, initialed by the physician,
that, in the physician's professional opinion, the qualifying patient is likely
to receive therapeutic or palliative benefit from the qualifying patient's
medical use of marijuana to treat or alleviate the qualifying patient's
debilitating medical condition;
h.
A statement, initialed by the physician, that, if the physician has referred
the qualifying patient's custodial parent or legal guardian to a dispensary,
the physician has disclosed to the qualifying patient's custodial parent or
legal guardian any personal or professional relationship the physician has with
the dispensary;
i. An attestation
that the information provided in the written certification is true and correct;
and
j. The physician's signature
and the date the physician signed; and
5. A current photograph of the qualifying
patient's custodial parent or legal guardian;
6. For the Department's criminal records
check authorized in A.R.S. §
36-2804.05:
a. The qualifying patient's custodial
parent's or legal guardian's fingerprints on a fingerprint card that includes:
i. The qualifying patient's custodial
parent's or legal guardian's first name; middle initial, if applicable; and
last name;
ii. The qualifying
patient's custodial parent's or legal guardian's signature;
iii. If different from the qualifying
patient's custodial parent or legal guardian, the signature of the individual
physically rolling the qualifying patient's custodial parent's or legal
guardian's fingerprints;
iv. The
qualifying patient's custodial parent's or legal guardian's address;
v. If applicable, the qualifying patient's
custodial parent's or legal guardian's surname before marriage and any names
previously used by the qualifying patient's custodial parent or legal
guardian;
vi. The qualifying
patient's custodial parent's or legal guardian's date of birth;
vii. The qualifying patient's custodial
parent's or legal guardian's Social Security number;
viii. The qualifying patient's custodial
parent's or legal guardian's citizenship status;
ix. The qualifying patient's custodial
parent's or legal guardian's gender;
x. The qualifying patient's custodial
parent's or legal guardian's race;
xi. The qualifying patient's custodial
parent's or legal guardian's height;
xii. The qualifying patient's custodial
parent's or legal guardian's weight;
xiii. The qualifying patient's custodial
parent's or legal guardian's hair color;
xiv. The qualifying patient's custodial
parent's or legal guardian's eye color; and
xv. The qualifying patient's custodial
parent's or legal guardian's place of birth; or
b. If the qualifying patient's custodial
parent's or legal guardian's fingerprints and information required in
subsection (B)(6)(a) were submitted to the Department as part of an application
for a designated caregiver registry identification card, dispensary agent
registry identification card, or laboratory agent registry identification card
within the previous six months, the registry identification number on the
registry identification card issued to the patient's custodial parent or legal
guardian serving as the qualifying patient's designated caregiver as a result
of the application; or
c.
Documentation that the custodial parent or legal guardian has a valid level I
fingerprint clearance card issued according to A.R.S. §
41-1758.07;
and
7. The applicable
fees in R9-17-102 for applying to renew a:
a. Qualifying patient's registry
identification card, and
b.
Designated caregiver's registry identification
card.
C. Except
as provided in subsection (A)(6), to renew a qualifying patient's designated
caregiver's registry identification card, the qualifying patient shall submit
to the Department, at least 30 calendar days before the expiration date of the
designated caregiver's registry identification card, the following:
1. An application in a Department-provided
format that includes:
a. The qualifying
patient's first name; middle initial, if applicable; last name; and suffix, if
applicable;
b. The registry
identification number on the qualifying patient's current registry
identification card;
c. The
designated caregiver's first name; middle initial, if applicable; last name;
and suffix, if applicable;
d. The
designated caregiver's date of birth;
e. The designated caregiver's Arizona
residence address and Arizona mailing address;
f. The county where the designated caregiver
resides;
g. The registry
identification number on the designated caregiver's current registry
identification card;
2.
If the designated caregiver's name in subsection (C)(1)(a) is not the same name
as on the designated caregiver's current registry identification card, one of
the following with the designated caregiver's new name:
a. An Arizona driver's license,
b. An Arizona identification card,
or
c. The photograph page in the
designated caregiver's U.S. passport or a U.S. passport card;
3. A current photograph of the
designated caregiver;
4. A
statement in a Department-provided format signed by the designated caregiver:
a. Agreeing to assist the qualifying patient
with the medical use of marijuana; and
b. Pledging not to divert marijuana to any
individual or person who is not allowed to possess marijuana pursuant to A.R.S.
Title 36, Chapter 28.1; and
5. For the Department's criminal records
check authorized in A.R.S. §
36-2804.05:
a. The designated caregiver's fingerprints on
a fingerprint card that includes:
i. The
designated caregiver's first name; middle initial, if applicable; and last
name;
ii. The designated
caregiver's signature;
iii. If
different from the designated caregiver, the signature of the individual
physically rolling the designated caregiver's fingerprints;
iv. The designated caregiver's
address;
v. If applicable, the
designated caregiver's surname before marriage and any names previously used by
the designated caregiver;
vi. The
designated caregiver's date of birth;
vii. The designated caregiver's Social
Security number;
viii. The
designated caregiver's citizenship status;
ix. The designated caregiver's
gender;
x. The designated
caregiver's race;
xi. The
designated caregiver's height;
xii.
The designated caregiver's weight;
xiii. The designated caregiver's hair color;
xiv. The designated caregiver's
eye color; and
xv. The designated
caregiver's place of birth; or
b. If the designated caregiver's fingerprints
and information required in subsection (C)(1)(j)(i) were submitted to the
Department as part of an application for a designated caregiver registry
identification card, dispensary agent registry identification card, or
laboratory agent registry identification card within the previous six months,
the registry identification number on the registry identification card issued
to the designated caregiver as a result of the application; or
c. Documentation that the designated
caregiver has a valid level I fingerprint clearance card issued according to
A.R.S. §
41-1758.07;
and
6. The applicable fee
in R9-17-102 for renewing a designated
caregiver's registry identification card.
Notes
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