Renewal Patient Paperwork

I understand that the physician may be contacted to verify and/or authorize my status as their patient as well as any prescsription and/or recommendation that may or may not be issued by them. By signing below, I hereby authorize the physician and /or THCMC to make such verifications or authorizations. My signature below shall serve as a release for this purpose only and shall not serve as a waiver of my other patient and physician privacy rights as detailed under Alaska and Federal HIPAA regulations. I understand if the physician requests medical records, follow-up appointments, prescription medications or anything else pertaining to my medical marijuana recommendation, my recommendation will become null and void if the the request is not fulfilled within 30 days. I understand that I am not legal to use medical marijuana until I mail my state application to Juneau and receive my Medical Marijuana Registry Patient Card. I understand that I must see my MMJ doctor once a year. By signing below, I agree that if, for any reason I need a replacement of my original Physician's Statement, I will pay a clerical fee of $75 if it has been longer than 30 days since my appointment.

I hereby designate Dr. John McGroarty as my Primary Care Physician.