Bring This Form to Your Practitioner

Minnesota Medical Cannabis Program

Patient E-Mail and Acknowledgement Form

 

Enter the email address you want Ie use for the Minnesota Medical Cannabis Patient Registry:

This is the email address to which the Minnesota Department of Health will send you information to complete your on- line application for enrollment in the Medical Cannabis Patient Registry.

The Minnesota Medical Cannabis Patient Registry is a state program run through the Minnesota Department of Health (MDH). When a government entity collects private information from a person, the entity must give the person a Tennessen notice. The purpose of this notice is to enable you to make an inforrried decision about whether to give information about yourself to the government entity.

Purpose and Intended Use

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.

The health care practitioner who certifies your qualifying medical condition for the purposes of the Patient Registry is required by law to report to MDH your health recoids related to the qualifying medical condition. The health care practitioner may release these records to l'v1DH without your written consent.

Classification of Data Provided

The information contained in the Patient Registry is considered private data on individuals, which means that data are not public but accessible to the individual subject of that data. Your email address will serve as your user name during account registration. If you choose to create an amine patient regi.stry account, your user name, password and answers provided to security questions as part of the registration process are also considered private data.

Requirements to Provide

You are not legally required to provide any of the requested infnfniat!on.

If you have any questions or concerns about why you are being asked for information or how it will be used, please contact us:

by email: health.cannabis@state.rr.n.us or

by telephone: 651-201-5598 (in tñe metro) 844-879-3381 (non-metro)

Consequences of Supplying or Refusing to Supply Information

Providing the information requested by the Patient Registry will determine whether or not you are eligible to participate in the Medical Cannabis Patient Registry pro¿;ram. Enrollment in the Patient Registry is required in order for medical cannabis to be distributed to you. However, if you choose to not provide all the required information, we will be unable to create your medical cannabis patient registry account arid you will not be able to enroll in the medical cannabis program. State law requires that applications for enrollment in the Medical Cannabis Patient Registry be completed on a form prescribed by MOH and certain minimum information may be required. Failure to provide any of the requested information could result in the delay or denial of your initial or renewal application, and of your ability to participate in the Medical Cannabis Patient Registry.

Other Persons or Entities Authorized to Receive Your Information

Pharmacy staff at state-registered medical cannabis man‹Jfacturers will ask you for information, and will also be able to review and use information in the Patient Registry to determine an appropriate composition and dosage of medical cannabis.

The health care practitioner who certifies your qualifying medical condition for the purposes of the Medical Cannabis Patient Registry may view your information in the Patient Registry.y.

If you have a designated caregiver to obtain anci/or administer your medical cannabis, your caregiver may access information to review composition and dosage information for your safety. The caregiver may also access and/or complete your self-evaluation report.

Law enforcement officials may access the information you provide to the Medical Cannabis Patient Registry only if they obtain a search warrant

Acknowledgement

By creating a Medical Cannabis Patient Registry account, you are indicating that you have read and understand this notice and the intended use of the data ar.d information you private data provide.