Acknowledgement of Receipt of Notice of Privacy Practices

    The information requested by the Medical Cannabis Patient Registry will be used to communicate with you, establish your eligibility and identity, and for MDH to evaluate information on patient demographics, effective treatment options, clinical outcomes, and quality-of-life outcomes for the purpose of reporting on the benefits, risks and outcomes regarding patients with a qualifying medical condition engaged in the therapeutic use of medical cannabis.

    Printed Patient Name*
    E-mail*
    Date*
    If completed by patient's personal representative, Please print name and sign below

    Printed Patient's Personal Representative Name
    Relationship to patient
    Patient's Personal Representative Name
    Date

    For Minnesota medical and rehabilitative sercices Offic Use Only

    Complete this form if unable to obtain signature of patient or patient's personal representative. Minnesota medical and rehabilitative services made a good faith effort to obtain patients written acknowledgement of Notice of Privacy Practices but was unable to do so for the reasons documented below

    Patient or Patient's personal representative refused to sign
    Patient or Patient's personal representative refused to sign
    other
    Printed Employee Name
    Date