Cannabis Certification (MMMP)

Cannabis Certification (MMMP)

Our physicians will evaluate your current medical condition to determine if you qualify for a medical marijuana certification under the State of Michigan's Medical Marijuana Program registry. Only residents of the State of Michigan may apply to the MMMP registry. Residency requirements are a valid (one that expired after March 1st, 2020) Michigan Driver License, Identification Card, or out of state license alongside a Michigan Voter Registration Card. To be evaluated by a doctor you must complete this interactive form and make your payment. Once you've accomplished this, we will provide you a link to our doctor's virtual waiting room.

Get Certified

Thank you for submitting the intake form. Complete your payment on the next page before seeing the doctor.

Previous Medical Cannabis Evaluation Information

Please provide the name of the facility or doctor who previously evaluated you for cannabis along with the the year of your last evaluation. If you do not remember either answer, you may move on the the next step.

Previous certifying Authority

The year that you were last seen for a medical cannabis certification

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Personal Information

Please provide the necessary personal details for us to begin your intake process.

Your legal first name as displayed on your government issued photo identification.

The first letter of your middle initial as presented on your government identification.

Your last name as presented on your government issued photo identification.

Your date of birth as presented on their government issued identification

The phone number you prefer we use for contact.

The email you prefer we use for contact.

The mailing address you'd like associated with your account.

The address must be located in Michigan.

The zip code associated with your mailing address.

The issuing authority of your governement photo identification.

A photo of the front of your Driver License or Identification card.

A photo of the back of your Driver License or Identification.

Photo of entire passport when opened to the identifying information page.

A photo of your valid Michigan Voter Registration Card.

Your Driver License/Identification Card number.

The date your Driver License/Identification Card was issued.

The date of expiration for your Driver License/Identification Card.

The country that issued your passport to them.

Your passport number.

The date your passport was issued.

The date of expiration of your passport.

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Caregiver Information

Provide the information required about your Caregiver by the State of Michigan.

The legal first name of your caregiver as displayed on their Michigan issued photo identification.

The first letter of your caregiver's middle name as it is presented on their Michigan Driver License or Identification Card.

Your caregiver's last name as it is presented on their Michigan Driver License or Identification Card

Your caregiver's date of birth as presented on their government issued identification

The phone number your caregiver prefers we contact them.

What is your caregiver's email address?

The mailing address your caregiver would like associated with your application.

The address must be located in Michigan.

The zip code associated with their mailing address.

Is this person listed as your caregiver listed on the back of your current MMMP card?l

The Caregiver Registry Number issued by the State of Michigan to your caregiver the last time you received your MMMP Card. This can be found on the back of your card.

Select the state that issued their government issued photo ID.

A photo of the front of your caregiver's Driver License or Identification Card. If not available at the moment you may leave this empty.

A photo of the backside of your Caregiver's government issued identification. If not available at the moment you may leave this empty.

Photo of entire passport when opened to the identifying information page.

A valid Michigan Voter Registration Card is required for caregivers with an out of state ID.

Your caregiver's driver license/identification card number.

The date of expiration for your Caregivers government issued photo ID

The country that issued your caregiver's passport to them.

Your caregiver's passport number.

The date your cavergiver's passport was issued.

The date of expiration for your Caregivers passport

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Referral Source

How did you hear about us today?

Internet

Dispensary


Grow Store

Friend/Word of Mouth



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Caregiver Designation

Do/will you have a caregiver attached to your MMMP Card?

Yes

Yes, I have made arrangements with a third party person that I am designating as my caregiver.

No

No, I do not have a third party person being designated as my caregiver at this time.

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Severity of Condition

How severe is the pain of your condition on a scale of 1-10? 10 being most severe.











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Cannabis Effectivness

How effective is cannabis for your medical condition on a scale of 1-5? 5 being most effective.






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Preferred Cannabis Consumption Method(s)

If you do, what is your preferred method of using cannabis? (Check all that apply)







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Cannabis Consumption Rate

How frequently do you consume cannabis?

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Prior Cannabis Use

Have you ever tried cannabis? Please answer honestly even if it was prior to the passage of Proposal 1.

Yes

I have tried or used cannabis in the past.

No

I have never tried nor used cannabis in the past.

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Condition Details

Provide detailed information regarding your qualifying condition(s) selected in the previous step.

When did your condition(s) start? You may put either a year or the age you were.

List any doctors or healthcare facilities you have visited in the past for the condition(s) selected. Include the name(s) as well as location(s) of any/all providers.

What have they told you is your diagnosis or is causing the qualifying condition(s)?

List any procedures or treatments used to evaluate and diagnoise your codition(s).

What effect did the treatment have on you afterwards?

How frequently do you experience pain or symptoms of your condition(s)?

Have you continued to receive treatment for the condition(s) since it began? If so, what types of treatments and how often?

How does the condition or pain cause you problems in your daily life? What kinds of things does it limit you from doing when it is most severe?

When is the last time you discussed these complaints with this provider? (Formatting example: 01/01/2020)

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Filing Option

Choose who will file your paperwork to the State of Michigan.

You File : $70.00

You will file on your own. You will receive a physical copy of your application and certification alongside an instruction sheet through the USPS within 5-7 business days.

We File : $135.00

We will file your application to the State of Michigan online. You will receive an email with your Patient Registry Number within 24 hours. You can use this to enter medical dispensaries immediately.

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MMMP Patient Registry Information

Please provide your MMMP license number and PIN Code

MMMP Patient Registry Number

Your MMMP Registry card number. If you do not have your previous card, deselect this option.

MMMP Patient Registry Pin

Your MMMP Registry card PIN. If you do not have your previous card, deselect this option.


Located at top of card.

Located under the P in bottom right corner.

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State That Issued Your Cannabis License

Was your most recent medical marijuana card issued through Michigan or another state?

Michigan

I was issued a medical cannabis license through the Michigan Medical Marijuana Program.

Out of State

I was issued a medical cannabis license through a state other than Michigan.

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Prior Medical Cannabis History

Have you ever been evaluated for medical cannabis prior to your visit with us today? It does not matter if it was in a different state.

Yes

I was previously evaluated for medical cannabis either in Michigan or another state.

No

No, I have not been evaluated for medical cannabis in the past. I am a new medical cannabis patient.

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Qualifying Medical Conditions

Select any condition(s) you have now or have had in the past. Condition(s) must be previously diagnosed by a physician (MD or DO)

Chronic Pain

Tourette's Syndrome

Parkinson's Disease

Ulcerative Colitis

Inflammatory Bowel Disease

Colitis

Spinal Cord Injury

Cachexia or Wasting Syndrome

Rheumatoid Arthritis

Arthritis

Obsessive Compulsive Disorder

Post-Traumatic Stress Disorder

Severe and Persistent Muscle Spasms

Including but not limited to those characteristic of Multiple Sclerosis

Seizures

Including but not limited to those characteristic of epilepsy

Severe Nausea

Severe and Chronic Pain

Cancer

Nail Patella

Agitation of Alzheimer's Disease

Crohn's Disease

Amyotrophic Lateral Sclerosis (ALS)

Hepatitis C

AIDS

HIV Positive

Glaucoma

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Emergency Contact Information

The contact information for your emergency contact.

Your emergency contact's first name.

Your emergency contact's last name.

Your emergency contact's phone number. (Formats: 2345678910, 234-567-8910, +12345678910)

How your emergency contact is related to you.

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Best Time to Reach You

Select the best time of day for us to reach you.

Morning

Afternoon

Evening

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Preferred Contact Method

Which method is the best way we can get ahold of you?

Phone Call

Text Message

Email

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Contact Information

Basic contact information to provide to the MRA. This information must be exactly as printed on your Driver License, Identification Card, or Passport.

Your first name as printed on your proof of residency. If you have multiple separate them with hyphens. (ex: Essential-Telehealth)

The first letter.of your middle name as printed on your proof of residency.

Your last name as printed on your proof of residency. .


Your date of birth as printed on your proof of residency (Format: 01/01/1980)

The primary phone number to reach you. (Formats accepted: 234-567-8910, 2345678910, +12345678910)

Best email address for us to contact you.


If work is not your primary phone. (Formats accepted: 234-567-8910, 2345678910, +12345678910)

If mobile is not your primary phone. (Formats accepted: 234-567-8910, 2345678910, +12345678910)

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MRA Online Account Login

Information that will be provided to the Marijuana Regulatory Agency to generate an account for you.

Preferred username to associate with your MRA account. (4 to 32 characters. May contain letters, numbers, and these special characters: @ _ - .)

Preferred email address to associate with your MRA account. Cannot be associated with another License and Regulatory Affairs (LARA) account.


Used for identification if you forget your MRA login information.

Answer to your security question. (40 characters maximum)

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Mailing Address Information

The mailing address you'd like to associate with your MMMP application.

Your mailing address. PO Box is acceptable. Does not have to match your license.

Your apartment, suite, lot, or unit if applicable.

The city in-which your address is located.

Your address is required to be in Michigan.

The 5 digit postal code for your city.

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Identification Information

The final price is:

Was your Driver License/Identification Card issued by the State of Michigan or by another state?

Select the date of issue for your Driver License/Identification Card

Select the date of expiration for your Driver License/Identification Card

Required by all patients. Ensure the photo is clear, taken directly above the license, and all four edges are showing. It is recommended to take the photo on a dark background. Scans are acceptable.

Required by all patients. Ensure the photo is clear, taken directly above the license, and all four edges are showing. It is recommended to take the photo on a dark background. Scans are acceptable.

For renewals who have their previous MMMP card. It is recommended, but not required, to upload expired MMMP cards.

For renewals with a caregiver and would like to retain them. It is recommended, but not required, to upload expired MMMP cards.

For applicants using an out of state ID or passport uploading your Michigan voter registration card is required.

Provide any additional information or details for the doctor that are pertinent to your certification that have not yet been covered.

Summary

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TERMS OF SERVICE

Overview





Laws govern how Essential Telehealth, LLC, A Michigan Professional Corporation (collectively 'we'/'us') can use and disclose health information that 'individually identifies' you. We call this information 'protected health information' or 'PHI'. We collect PHI when you use our App and Website and when you communicate with us.





This Privacy Policy helps you understand a) how we'll use and share your PHI, b) what rights you have over your PHI and how to exercise your rights, c) what to do if you think we're not complying with our legal obligations, and d) what other information we collect and share when you use the Essential Telehealth mobile application ('the App') or Website.





If you have any questions, please send us a message through the App or Website or call us at 800.345.5414 during business hours, Monday to Sunday. Our normal business hours are 10:00am to 6:30pm Eastern Time Monday to Saturday. 12:00pm to 6:30pm Sunday.





How we use and disclose your PHI





We use and disclose your PHI to provide you with care, to run our healthcare operations, to take payment and to comply with regulations. We implement a range of technical, administrative and physical safeguards to protect your PHI.





We use your email address to send you a range of different types of emails, including but not limited to emails that update you as to the status of your request for a prescription or laboratory test, to send you emails that alert you that there is a message waiting for you in the App or Website, to send you emails asking for feedback on your experience of using the service, to send you emails to notify you that you may be due for a refill, and to send you emails if you create an account but fail to complete a visit. We will send you marketing emails to notify you of the services we provide. We will share your email and first name with third party email platforms to enable us to send you emails.





We use your telephone number to call you if we have any questions, to leave you voice messages if you don't answer the telephone when we call you, and to call you to ask for feedback on your experience of using the service. We also use your telephone number to send you SMS/text message notifications. We may send you SMS notifications to update you on the progress of your visit. If you ask us to organize for a partner pharmacy to mail your medicines, we may telephone you to take payment on behalf of the pharmacy and we may SMS you to let you know that you have refills available.





To provide treatment and to run our healthcare operations and to take payment we share your PHI with selected organizations that provide us with services.





As examples, we share your PHI with organizations that help us run and maintain the technology and security infrastructure that supports the App and Website and the care we provide. We also may share your health information with medical staff who help ensure that we are providing a service that meets the appropriate standard of care.





We share your PHI and card details with our trusted online payment processors. If you choose to save your payment details to make future payments easier, our trusted payment provider will store them on our behalf. Furthermore, if you request delivery of your medicines by mail from a third party pharmacy then our trusted payment processor will always store your card details to make future payments more convenient.





We share your PHI with the pharmacy if we give you a prescription and with intermediaries who enable us to send prescriptions electronically. If you request that we organize for a partner mail order pharmacy to deliver your medicines, then we will share your PHI with and send your prescription to one or more mail order pharmacies so that there is flexibility in terms of which pharmacy mails your first deliver and which pharmacy mails any subsequent deliveries.





If we order laboratory tests for you then we share your PHI with the lab company that runs the tests. If a laboratory test we order for you finds a 'reportable' infection we may be required by law to share your PHI to your county health department.





We share your telephone number with the company that helps us send SMS/text messages. If we need to telephone you then we share your telephone number with our telecommunication provider.





If you decide to schedule a call-back from our medical team, you will enter your email and first and last name into Google Calendar. Google will protect your information according to their Privacy Policy that is available on their website.





We store information you provide us with whether you complete a visit or whether you do not complete a visit. We take the same precautions over your data regardless of whether you complete a visit.





We do not record video visits between our patients and our doctors. We may, however, capture a still image from the video and store that image in your medical record.





We may use your PHI to tell you about health-related products and services.





We may share your PHI with a third party if we merge, are acquired or undergo an asset sale.





Wherever possible we strive to make sure that any third parties with whom we share your PHI are legally bound by the restrictions of this Privacy Policy.





We are generally unable to delete information from your medical record. At your request we can de-activate your secure account so that you and others can no longer access it with your username and password.





Other information we collect





Separate to the health information we collect, we collect technical information about how you use our App and Website. We use this information to help us improve the overall quality of the App and Website, improve the service we provide, and improve our advertising and marketing campaigns.





Technical information we collect and may share with Facebook, Google, AppsFlyer Ltd., Microsoft (Bing Ads) and Zopim Technologies Pte Ltd / Zendesk Inc includes information about your mobile device or computer, including but not limited to unique device identifiers and the operating system and browser you use, and information about when and how you use the App or Website, including specific pages you visit, and information about your general location when you use the App and Website, including but not limited to your internet protocol address and MAC address. Facebook, Google, AppsFlyer Ltd., Microsoft and Zopim Technologies Pte Ltd / Zendesk Inc are not bound by the terms of this Privacy Policy as to how they use technical information about you but are instead bound by the Facebook, Google Analytics, AppsFlyer Ltd., Microsoft Bing Ads and Zopim Technologies Pte Ltd / Zendesk Inc Terms of Use and Privacy Policies that are available on their respective websites.





We use 3rd party vendor re-marketing tracking cookies, including the Google Adwords and Steel House and Facebook tracking cookies. This means we will continue to show ads to you across the internet. The third-party vendors will place cookies on web browsers in order to serve ads based on past visits to our website. Third party vendors, including Google and Steel House and Facebook, use cookies to serve ads based on a user’s prior visits to your website. This allows us to make special offers and continue to market our services to those who have shown interest in our service.





We do not respond to 'do not track' signals in your browser.





Risk of sending unencrypted emails





The emails we send you are not secure because they are unencrypted. Other people may be able to read and forward the emails we send you and the emails you send us. Emails we send you may include a wide range of identifiers that include but aren't limited to your name, your email address, your visit number, your patient number, the date you used our service etc.





When you create an account on the App or Website we ask you to give us your email address. We send an email to the email address you give us. If you give us an incorrect email address we will unknowingly send an email to the wrong person.





Risk of sending unencrypted SMS/text messages





The SMS/text messages we send you are not secure because they are unencrypted. Other people may be able to read and SMS/text messages we send you and any SMS/text messages you send us.





SMS/text messages we send you will include your telephone number. It will be clear that SMS/text messages we send you have come from Essential Teleheatlh.





Risk of storing PHI on your mobile





When you use the App or Website there is a risk that your PHI will be stored unencrypted on your mobile. We take a variety of technical safeguards to make sure that your PHI does not leak onto your mobile but we cannot guarantee that these safeguards work.





Risk of our systems getting hacked and compromised





We take a number of administrative, technical and physical safeguards to look after the PHI that we hold electronically on our servers. But despite these safeguards, no system is full-proof and we cannot guarantee that our systems and your PHI will not be hacked or otherwise compromised by unauthorized third parties.





The rights you have over your PHI





Right to obtain a copy of your medical record. We are allowed to charge you a fee if we think it's appropriate.





Right to request that we limit how we use and share your PHI. There may be occasions when we cannot agree to your request.





Right to request that we change or update information held in your medical record. There may be occasions when we cannot agree to your request.





Right to request how we send you PHI. The electronic nature of our service limits our ability to agree to such requests.





Right to an accounting of the disclosure of your PHI. You are entitled to one 'disclosure accounting' in a 12 month period at no charge. An accounting does not include disclosures to carry out treatment, healthcare operations or payment. We are allowed to charge a fee for any additional accounting in a 12 month period.





Right to a paper copy of this Privacy Policy. The electronic nature of our service limits our ability to agree to such requests.





How to contact Essential Teleheatlh to Use your Rights





Please write to us at: The Privacy Officer, Essential Telehealth, 280 Collingwood Drive Suite B, Ann Arbor, Michigan 48103.





How to complain





To submit a complaint to Essential Telehealth you need to submit your complaint in writing to:





The Privacy Officer, Essential Telehealth, 280 Collingwood Drive Suite B, Ann Arbor, Michigan 48103.





In addition you can complain to:





Secretary of the U.S. Department of Health and Human Services
Office for Civil Rights
Attention: Regional Manager
U.S. Department of Health and Human Services
233 N. Michigan Ave., Suite 240
Chicago, IL 60601





For additional information, call (800) 368-1019





or





U.S Office of Civil Rights (866) 627-7748 (Voice) or (866) 788-4989 (TTY)





No retaliation





We will not retaliate against you for filing a complaint.





Effective date





This Notice is effective dated April 20th, 2020.





Changes to this Notice





If we change the terms of this Privacy Policy then we will post the new Privacy Policy on our App and Website. Any new Privacy Policy will apply to all PHI that we maintain, including PHI that was created prior to the change.


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