Oregon Medical Marijuana Program Attending Provider's Statement
This file is the Oregon Medical Marijuana Program (OMMP) Attending Provider's Statement. It must be completed by the patient's attending provider to comply with OMMP registration requirements. The form includes patient and provider information, medical conditions, and provider certification sections.
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How do I fill this out?
To fill out this form, follow the instructions provided for each section. Ensure all patient and provider information is accurate and complete. Make sure to sign and date the form before submitting it.
How to fill out the Oregon Medical Marijuana Program Attending Provider's Statement?
1
Fill out the patient information section.
2
Complete the provider information section.
3
Check the appropriate debilitating medical conditions.
4
Certify the form by signing and dating it.
5
Submit the form to the OHA/OMMP mailing address.
Who needs the Oregon Medical Marijuana Program Attending Provider's Statement?
1
Patients applying for registration in the Oregon Medical Marijuana Program need this form.
2
Attending providers certifying patients' medical conditions for the OMMP need this form.
3
Patients renewing their OMMP registration need this form.
4
Providers updating their patient's medical conditions for OMMP need this form.
5
Patients and providers ensuring compliance with OMMP requirements need this form.
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Use the text tool to fill in the required fields.
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What are the instructions for submitting this form?
Submit the completed form via mail to OHA/OMMP PO Box 14450 Portland, OR 97293-0450. Ensure all sections are filled out correctly and the form is signed and dated. For further assistance, contact the OMMP at (971) 673-1234.
What are the important dates for this form in 2024 and 2025?
Ensure to submit the form within 90 days of the provider's signature date. You cannot renew more than three months prior to your current card expiration date.
What is the purpose of this form?
The purpose of this form is to comply with the registration requirements of the Oregon Medical Marijuana Program (OMMP). The OMMP Attending Provider's Statement must be completed by the patient's attending provider, who certifies the patient's debilitating medical condition(s). This form ensures that patients receive the necessary certification for the medical use of marijuana, as per OMMP guidelines.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Includes fields for patient name, date of birth, and mailing address.
- 2. Provider Information: Includes fields for provider name, mailing address, phone number, and medical license type.
- 3. Debilitating Medical Condition: Provides checkboxes for various medical conditions that qualify for the medical use of marijuana.
- 4. Provider Certification: Certifies that the provider has primary responsibility for the patient's care and treatment and includes a signature and date field.
What happens if I fail to submit this form?
Failure to submit this form may result in denial or delay of OMMP registration.
- Registration Denial: Your application for medical marijuana use may be denied if the form is not submitted.
- Registration Delay: A delay in your registration process can occur if the form is not submitted on time.
How do I know when to use this form?
- 1. New Applications: Complete this form when initially applying for the OMMP.
- 2. Renewal Applications: Use this form when renewing your OMMP registration.
- 3. Medical Condition Updates: Submit this form if there are updates to your medical condition.
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What information do I need to fill out the OMMP Provider Statement?
You need patient and provider information, medical conditions, and provider certification.
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How do I submit the completed OMMP Provider Statement?
Submit the completed form to the OHA/OMMP mailing address provided in the instructions.
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