Life Medical P.A. 4201 Excelsior ST. Louis Park, MN 55416 Tel : 952 933 8900 FAX : 952-945-9536 I acknowledge that I am paying $ certification fee for medical cannabis certification I authorize Life Medical to charge my health insurance for today's visit with Dr. My certification fee will cover all the costs associated with my deductible, co-insurance and/or co-pays if any and I will not owe anything else for today's visit Patient's Name * Date * E-mail