Medical Marijuana Intake

Medical Marijuana Intake
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Allergies - Name, Drug,and Reaction, including any type of anesthetic. Type NONE if you do not have any to list.*

Indication(s) for Cannabis Treatment
Chief complaint for evaluation of cannabis treatment*
RX Medication Name (Dosage / Regimen / Target Symptom)

Social History and Habits
Do you currently use marijuana?*

YesNo
If YES, how often and by what method, does it help alleviate symptoms of your qualifying condition?
Recreational Drug Use - Frequency/Type/Route, i.e. ingestion, injection, snorting

Acknowledgements, Agreements, Disclosures, Informed Consent
I, (Patient's Name) (Patient's Name) understand that medical marijuana is a medicine used in treating the suffering caused by serious and debilitating medical conditions.

Serious and debilitating medical conditions include: Cancer, HIV/AIDS, Epilepsy, Multiple Sclerosis, Parkinson's disease, ALS (Lou Gehrigs's disease), damage to the nervous tissue of the spinal cord with objective neurological indication of intractable spasticity (any spinal cord injury), Inflammatory Bowel Disease, Huntington's disease, any type of neuropathy, any condition that is severe, for which other medical treatments have been ineffective, and if the symptoms "reasonably can be expected to be relieved" by the use of cannabis. Additionally, medical marijuana is used in the treatment of other chronic or persistent medical
symptoms that:

•  Substantially limits the ability of the person to conduct one or more major life activities as defined in the Americans with Disabilities Act of 1990 (Public Law 101-336)

•  If not alleviated, may cause harm to the patient's safety or physical or mental health

•  A chronic or debilitating disease or medical condition that causes severe loss of appetite wasting, severe chronic pain, severe nausea, seizures or severe or persistent muscle spasms, or glaucoma, or post-traumatic stress disorder (PTSD)

I have been advised that the use of medical marijuana may affect my coordination, motor skills and cognition in ways that could impair my ability to drive and agree not to operate heavy machinery, drive or engage in potentially hazardous activities.
I understand that side effects may occur while I am taking medical majuana. Side effects of medical marjuana may include but are not limited to: euphoria, difficulty in completing complex tasks, low blood pressure, sedation, dysphoria, alterations in the perception of time and space, dizziness, anxiety, confusion, impairment to short-term memory, inability to concentrate, depression of the body's immune system, increase talkativeness, impairment of motor skills, delayed reaction time, a physical coordination, paranoia, and increased eating.

I understand that some patients may become dependent on marijuana. This means they experience withdrawal symptoms when they stop using marijuana. Signs of withdrawal symptoms may include: feelings of depression, sadness, irritability, insomnia, restlessness, agitation, loss of appetite, trouble concentrating, sleep disturbances, and unusual tiredness.

I understand that chronic use of medical marijuana may lead to laryngitis, bronchitis, and general apathy.

I understand that although marijuana does not produce a specific psychosis, it may exacerbate schizophrenia in persons predisposed to that disorder.

I agree to tell the attending physicians if I have ever had symptoms of depression, been psychotic, attempted suicide or have any other mental problems. I also agree to tell the attending physician if I've ever been prescribed or taken medicine for any of the conditions stated above. Furthermore, I understand that the attending physician does not suggest nor condone that I cease treatment and or medication that stabilize my mental or physical condition.

I understand that there are few known interactions between marijuana and medications other than herbs. However, very few interactions between herbs and medications have been studied. I agree to tell my attending physician if I am using any herbs, supplements or other medications.

I am aware that a Notice of Compliance has not been issued under the Food and Drug Regulations concerning the safety and effectiveness of Marijuana as a drug. I understand the significance of this fact.

I am aware that medical marijuana has not been approved under Federal Regulations and I understand that medical marijuana has not been deemed legal under federal law.

I understand that some users might develop a tolerance to marijuana. This means higher and higher doses are required to achieve the same benefit. It is recommended for patients to have an intermission with the drug for at least 3 weeks every 3-4 months. If I think I may be developing any tolerance to marijuana, I will notify the attending physician.

I understand the benefits and risks associated with the use of marijuana are not fully understood and that the use of marijuana may involve risks that have not been identified. I accept such risk.

I understand should respiratory problems or other ill effects be experienced in association with the use of medical marijuana, I agree to discontinue its use and report any such problems or effects to the attending physician.
Do you agree to the above statement?*

I Agree

Medical Marijuana Patient Declaration
I hereby declare that I have completely and truthfully disclosed all information regarding any medical condition and attest that I do not intend to use my medical recommendation for the purpose of illegally obtaining, growing, or distributing medical marijuana.

I attest that I am not a member, employee or agent of any media or law enforcement agency. It is illegal to film or record in this office with a video camera, cell phone or any other recording device be it a still image, video or audio. This is a direct violation of HIPAA regulation and patient/doctor confidentiality.

I am aware that my recommendation can be revoked at any time and legal actions will be taken if I have perjured or misrepresented myself or my condition, my intentions or falsified any medical records to the physician. I also hereby authorize Natural Pain Solutions or it's representative, to discuss my medical condition for verification purposes only.

Additionally, I acknowledge the attending physician informed me of the nature of a recommended treatment, including but not limited to any recommendation regarding medical marijuana. The risks, complications and expected benefits of any recommended treatment, including its likelihood of success or failure.

I acknowledge the attending physician informed me of any alternatives to the recommended treatment including the alternative of no treatment, and their risks and benefits. The physician may request that I visit another physician or specialist to further substantiate my condition. I will be informed of all the above-mentioned regardless of whether or not I qualify as a patient.
Do you agree to the above statement?*

I Agree

Release of Liability
I attest that the information on this form is correct and any medical history presented or discussed with the doctor is all factual and complete to the best of my knowledge. I do not plan or intend to use my Physician's recommendation for the purpose of illegally obtaining medical marijuana. Soley for verification purposes, I authorize - Natural Pain Solutions - to converse of my medical condition.
I understand that I must be a New York resident to obtain an approval or recommendation for the use of medical cannabis.

I affirm that I have a serious medical condition that negatively affects my quality of life. I have found or am interested in finding out whether or not medical marijuana provides substantial and improvement in my condition.

I understand that the cannabis plant is not regulated by the United States Food and Drug Administration and therefore may contain unknown quantities of active ingredients, impurities, and/or contaminants. I understand the potential risks associated with an elevated daily consumption of medical marijuana including risks with the respect to the effect on my cardiovascular and pulmonary systems and psychomotor performance, risks, associated with the long-term use of marijuana, as well as potential drug dependency. I am aware that the benefits and risks associated with the use of marijuana are not fully understood and that the use or marijuana may involve risks that have not been identified. In requesting an approval or recommendation for the use of medical marijuana, I assume full responsibility for any and all risks involved in this action.

I have been advised that medical marijuana smoke contains chemicals known as tars may be harmful to my health. Recent research indicates that vaporizing cannabis may eliminate exposure to tar. Should respiratory problems or other ill effects be experienced in association with its use, it should be discontinued and reported to the physician immediately.

I was also advised that the use of medical marijuana might affect my coordination and cognition in ways that could impair my ability to drive, operate machinery, or engage in potentially hazardous activities. I assume full responsibility for any harm resulting to me and/or other individuals as a result of my use of cannabis.

New York's Medical Marijuana Act - Assembly Bill 6357, approved June 19, 2014 provides for the possession of the medical marijuana for the personal medical purposes of the patient with a physician approval or recommendation. It should be made clear that the physician, staff and

representatives of this practice are not providing medical marijuana, nor are they encouraging any illegal activity and obtaining medical marijuana.

I, the undersigned, hereby request a consultation by the physician for purposes of determining the appropriateness of medical marijuana treatment. I acknowledge that using cannabis as a medicine has been explained to me and that any questions that I have asked have been answered to my complete satisfaction. The physician, staff, and representatives are addressing specific aspects of my medical care, and unless otherwise stated are in no way establishing themselves as a primary care provider. Should an approval be made for my medical use of marijuana, I understand that there is a renewal date specified by the physician depending on the condition. I understand that it is my responsibility to see a physician to assess the possible continuance of cannabis used beyond the term of the approval.

Furthermore, the undersigned, or anyone acting on my behalf, hold the physician and his/her principles, agents, and employees, free of and harmless from any liability resulting from the use of medical marijuana.

I further understand that by signing below, I am authorizing the release of any part of this record, except for identifying information, for use in data analysis of medical marijuana treated patients.
Do you agree to the above statement?*

I Agree

Acknowledgement of Status
I certify that I am not taking any controlled substances/narcotics.*

YesNo
I certify that I am not currently in a drug rehabilitation or detoxification or treatment program nor am I receiving prescriptions for buprenorphine, naltrexone or methadone.*

YesNo
I certify that I have read this document and declare under the penalty or perjury that the information contained herein is true, correct and complete. I acknowledge that any manipulation, alteration or falsification of this form will result in the immediate termination of any legal right to my use of medical marijuana. Furthermore, natural pain solutions will report any of the above mentioned activities to the appropriate local authorities.*

YesNo

Notice of Privacy Practices Patient Acknowledgement Authorization for Use/Disclose of PHI
Acknowledgement of Privacy Notice
I have received the practice's Notice of Privacy Practices. The Notice provides in detail the uses and disclosures of my PHI (Protected Health Information) that may be made by this practice. I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices, and to make changes regarding all PHI at, or controlled by, this practice. I understand I can obtain this practice's Notice of Privacy on request.

Authorization for Use/Disclose of Protected Health Information (PHI)
I authorize the use and disclosure of all health information for the purpose of treatment, payment and Health Care Operations. I authorize Natural Pain Solutions and his staff to use these disclosures of my health information without limitation. I understand that information disclosed pursuant to this authorization may be re-disclosed to additional parties and no longer protected. I understand that any revocation. I authorize disclosure of my PHI to the following individual(s).

I understand that by signing this form I am confirming my receipt to the Notice of Privacy Practices; authorization for method of contact; and authorization for use and/or disclosure of any PHI.
Do you agree with the above statement?*

I Agree

HIPAA Notice of Privacy Practices Acknowledgement of Receipt
By signing this, I hereby acknowledge that I have read and understand the privacy practice notice and may obtain additional copies upon my request. This acknowledgement will be filed with my records.

I, (your name) , date of birth, (date of birth) hereby authorize Natural pain Solutions to disclose and verify me as a patient to any law enforcement agency, my physician(s), Child Protective services or any (state) (State) approved dispensary, This is valid during the period of time for which the recommendation has been issued, This consent is subject to written revocation only, at any time except to the extent that action has already been taken on the basis of this consent.

I give Natural Pain Solutions and the attending physician permission to validate my status as a patient using the Natural Pain Solutions online patient verification system.

I give permission for my medical records and file to be reviewed by another physician working with Natural Pain Solutions. I understand that this might happen if the original doctor that evaluated me requires a secondary opinion, is not available, off premise, has moved or terminated his/her practice.
Do you agree and understand the terms and conditions of the HIPAA privacy act?*

YesNo
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Relationship to Patient, if signed by a personal representative i.e. parent, legal guardian, etc.
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Should be Empty:

Medical Marijuana Intake

Indication(s) for Cannabis Treatment

Social History and Habits

Acknowledgements, Agreements, Disclosures, Informed Consent

Medical Marijuana Patient Declaration

Release of Liability

Acknowledgement of Status

Notice of Privacy Practices Patient Acknowledgement Authorization for Use/Disclose of PHI

HIPAA Notice of Privacy Practices Acknowledgement of Receipt