Page 1 Welcome to Colorado Medical Cannabis Patient Verification TABLE OF CONTENTS Member Rules and Regulations................ Page 2-3 CMCPV Patient Affirmation Form................ Page 4 Notice of Privacy Practices................... Page 5-6 Patient Intake Form....................... Page 7
Page 2 Rules and Regulations 1. Private Club: CMCPV is a cooperative organized to provide streamlined third party verification services for qualified medical marijuana patients consistent with the limitations and rights set out in the Colorado Constitution, Article XVIII, Section 14 and newly adopted local and statewide regulations including HB 1284 and SB 109. The following rules and regulations apply to all members of this cooperative and may be amended without notice to accommodate new rules and regulations. Any violation of these rules by a member is grounds for immediate termination of any legal relationship between the parties. 2. Generally: The CMCPV issues you a membership card ( Card ) that may provide an override for paperwork that is generally required in a medical marijuana facility. Any patient using the Card in an establishment that honors the Card (the Licensed Facility ) will typically not be required to fill out any forms, except for a sign-in sheet that provides for a quick pass system for verification through the Licensed Facility. Each Card has a unique password encoded for each patient that will all Licensed Facilities limited access to the patient s medical marijuana documentation, HIPPA releases, and any other documentation necessary such that the Licensed Facility may verify your status as a valid medical marijuana patient, electronically from a secure, encrypted web based application. Upon swiping the Card, the secure electronic system verifies the patient is in good standing. The Card is valid for a six month period from the date of your original doctor s visit. Once the state issues your official state registry card, CMCPV will then provide you with a new Card that will remain valid for a one year period from the date of state issuance. The CMCPV card DOES NOT REPLACE the state issued card and you are STILL REQUIRED to fulfill the state requirements for validating your medical marijuana patient status. 3. Recommendations and Confirmation of Diagnosis: Members of CMCPV must have a valid doctor s recommendation for medical marijuana pursuant to local and state regulation. Members may be asked to provide a copy of the following: (a) your Colorado Medical Marijuana Registry Card; (b) a copy of your doctor s recommendation; (c) a valid Colorado photo ID; (d) the recommending Physician s telephone contact information to ensure validity of the information; and (e) any and all relevant information to establish the legitimacy of your legal right as a Colorado Medical Marijuana patient. 4. Minimum Age; Only Patients and Caregivers Permitted in Club: Only patients or caregivers with the original and up-to-date Card or who comply with 1 of this section will be allowed into the club as members. 5. Confidentiality: All personal information collected by CMCPV is confidential and private. All personal information will not be released to any third party without your express written consent or as provided below. Members understand that CMCPV may be forced by Court order or relevant statutes to release certain information to parties that include, but are not limited to, law enforcement, the state licensing authority for medical marijuana and other permissible parties. You understand and approve of the release of
Page 3 these private medical records to legally entitled parties and understand and approve of CMCPV complying with all lawful orders in this regard. 6. Loss; Indemnity: If I lose my Card, it is my sole responsibility to immediately contact the CMCPV and cancel this Card, and that I indemnify and hold CMCPV harmless from any harm resulting from misuse of the lost Card, including all criminal and civil liabilities that may result therefrom. 7. No re-sale, re-distribution, or driving impaired: Re-sale or re-distribution of any products received from CMCPV by members is strictly prohibited. Members agree they will not to operate a motor vehicle or heavy equipment at any time impaired by medical marijuana. Members agree to indemnify and hold harmless CMCPV to the maximum extent allowed by law for any damages caused by the member operating a motor vehicle or heavy equipment or all actions in tort attributed to impairment by medical marijuana. 8. No Guarantee of Licensed Facilities: CMCPV makes no warranties or representations and provides no guarantees that the facility from which you decide to procure medical marijuana from will be a Licensed Facility of the CMCPV Card system. 9. Payment for services: I understand that my payment to CMCPV for third party verification services include fees for professional consulting services, overhead, expenses and other related costs of providing services. Payment is expected at time of service. 10. Declaration of Non-Law Enforcement Status: I declare that I am not employed by, under contract to, or in agreement with any municipal, local, provincial, federal or foreign law enforcement agency. 11. CMCPV reserves the right to refuse service and revoke service to any member at any time for any reason. I have read and understand the aforementioned Rules and Regulations. I agree to abide by all rules, regulations, and agreed upon terms. PATIENT Patient Printed Name: Date: Signature: CO DL#: Exp: Client Phone #: Email: Full Legal Address: Street/City/ State/Zip Relaxed Clarity, LLC Representative Witnessed by: Date: Printed Name: Title:
Page 4 CMCPV PATIENT AFFIRMATION As a patient, I choose to allow Relaxed Clarity, LLC with the aid of the CMCPV photo ID Card to serve as third party verification service regarding my status as a medical cannabis patient. In joining the CMCPV and in initialing the boxes below, I acknowledge that, in providing the CMCPV with my information I: Have a bona-fide physician/patient relationship with my physician, and that I have undergone a physical exam, any necessary treatment or counseling, and a full assessment of my medical history. Understand that my confidential information may be shared by Relaxed Clarity, LLC with CMCPV Licensed Facilities to verify my status as a valid medical cannabis patient. Affirm that all consultation(s) with my physician occurred prior to my applying for a state medical marijuana registry card thru the Colorado Department of Public Health and Environment Affirm that my physician is available to provide follow up care and to address any medical needs. Suffer from a debilitating medical condition that may benefit from medical marijuana. Have not offered any discount or compensation in exchange by CCBC for agreeing to assign a particular medical marijuana center, dispensary or primary caregiver to procure my registration card. Understand that if I lose my Colorado Medical Cannabis Patient Verification membership card, it is my sole responsibility to immediately call Relaxed Clarity, LLC and cancel this Card, and that I indemnify and hold Relaxed Clarity, LLC harmless from any harm resulting from misuse of the lost Card, including all criminal and civil liabilities that may result therefrom. Signed: Date: Printed Name:
Page 5 NOTICE OF PRIVACY PRACTICES This notice describes how medical information about you may be used and disclosed and how you can obtain access to this information. PLEASE REVIEW THIS CAREFULLY. Copies of this notice are available upon request. 1. OUR PLEDGE REGARDING MEDICAL INFORMATION The privacy of your medical is extremely important to us. We understand that your medical information is personal and we are fully committed to protecting it. To facilitate this process, we create a record of the care and services you receive through our organization. This record enables us to provide you with the necessary quality of care, and is also necessary to ensure that we comply with both state and federal legal requirements. This pledge is intended to provide you with information that will describe the ways in which we use and share your medical information. We also describe rights and duties we have regarding the use and disclosure of your medical information. Please understand that you are not bound to sign a HIPPA Authorization attached hereto. 2. OUR LEGAL DUTY Law requires us to: a. Keep your medical information private. b. Give you this notice describing our legal duties, privacy practices, and your rights regarding medical information. c. Follow the terms of this Notice. We have the right to: a. Change our privacy practices and the terms of this notice at any time without providing notice to you, provided that the changes are permitted by law. b. Make the changes in our privacy policy practice and the new terms of our notice effective for all medical information that we keep, including information previously created or received before changes. Notice of change to privacy practices: a. Before we make an important change in our privacy practices, we will change this notice and make the new notice available upon request. 3. USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION The following section describes different ways that we use medical information. It is imperative that you realize that not every use or disclosure will be listed. However, we have listed the different ways we are permitted to use and disclose medical information without first receiving express authority from you additional to that provided on the signed HIPPA Authorization. We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked by you, at any time, by writing to us at the address provided at the end of this notice. Specific uses: For Treatment: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses,
Page 6 technicians, medical students, licensed CMCPV medical marijuana card centers, or other people who are addressing your medical needs. We may also share your medical information with other health care providers to assist them with treating your medical needs. For CMCPV Card Services: We may disclose medical information about you to Licensed CMCPV facilities for the sole and exclusive purpose of providing the Licensed Facility with the information necessary to confirm your status as a legal medical marijuana patient in the state of Colorado. Such disclosure shall be limited to providing the Licensed Facility with only as much medical information is necessary to: (i) confirm your status as a legal medical marijuana patient in the state of Colorado pursuant to Colorado law; and (ii) to comply the Licensed Facilities stated requirements. For Payment: We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third party payer. The information on or accompanying the bill may include your medical information. 4. YOUR INDIVIDUAL RIGHTS You have the right to: a. Look at or receive copies of certain components of your medical information. You must make your request in writing. b. Receive a list of all the times we or our business associates shared your medical information for purposes other than treatment, payment, health care operations and other specified exceptions. c. Request that we communicate with you about your medical information by different means or at different locations. Your request that we communicate your medical information to you by different means or at different locations must be in writing. d. Request that we change certain parts of your medical information. We may deny your request if we did not create the information you want changed or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement that will be added to the information you wanted to change. If we accept your request to change the information, we will make reasonable efforts to tell others, including people you name, of the change and to include the changed information in any future sharing if information. If you have questions about this notice or if you think your rights to privacy have been violated please contact us immediately Relaxed Clarity, LLC 1006 Depot Hill Rd. Suite 100, Broomfield CO, 80020 In signing below I acknowledge that I have reviewed and understand the aforementioned Notice of Privacy Practices. Printed Name: Signature:
Page 7 Personal Information Medical Cannabis Patient Intake Form Full name: Home address: Home phone: Work phone: Cell: Email: Your Birthdate: Medical Marijuana History Do you have a debilitating medical condition? If so, what is your condition? Have you received a recommendation from a doctor that you may benefit from the medical use of cannabis for your debilitating medical condition? Relaxed Clarity, LLC prefers to contact your doctor to confirm your recommendation. May we contact your doctor for that limited purpose? If yes, what is the name and contact information of the doctor who recommended you medical marijuana? Name: Contact Info: Do you presently have a Medical Marijuana Registry Identification Card? If so, what are the valid dates on that Card?