In-Office. New patient. Card renewal.

Completion time: 10-14 minutes

This form is for:

Patients new to our practice
FL med card renewal and doctor change

Protected Health Information (PHI)

The personal information we collect is necessary for you to apply to the State Registry. We upload required identifying data to the Florida state OMMU registry to get your marijuana card. This info is considered PHI and although we store it on our local computer, we use it solely for the purposes of this business transaction. We do not share, sell, or give access to any third party, nor do we send it to, or store it, in the 'cloud'. Our privacy notice is below.

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Step 1 of 10

Ever apply for a Florida med card before?

RELEASE of LIABILITY

I attest that I am a Florida resident and 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 purposes of illegally obtaining, growing, or distributing medical marijuana. I am aware that the KindHealth doctor will revoke my recommendation and legal actions will be taken if it is found at any time that I have perjured or misrepresented myself or my condition, intentions, or falsified any medical records to the physician. Solely for verification purposes, I authorize the KindHealth staff/contracted doctors to converse regarding my medical condition.

I understand the United States Food and Drug Administration does not regulate cannabis and it may therefore 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 respect to the effect on my cardiovascular, pulmonary systems and psychomotor performance. There are also risks associated with the long-term use of marijuana as well as potential drug dependency. I am aware the benefits and risks of using marijuana are not fully understood and may involve risks not yet identified. In requesting an approval or recommendation for the use of medical marijuana, I assume full responsibility for any risk involved in this action.

I understand medical marijuana smoke contains chemicals known as tars that may be harmful to my health. Research indicates that vaporizing cannabis may eliminate exposure to tar. If I experience any respiratory problems or other ill effects be experienced in association with its use, I should discontinued its use and report to the physician immediately.

I am advised 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 cannabis use.

Florida’s Medical Marijuana Legalization Initiative - Amendment 2, approved November 08, 2016 provides for the possession of medical marijuana for the personal medical purposes of the patient with a physician approval or recommendation. KindHealth staff, physicians and/or representatives are not providing medical marijuana, nor are they encouraging any illegal activity in my obtaining 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 devise be it a still image, video or audio. This is a direct violation of HIPAA regulations and patient/doctor conﬁdentiality.

I, the undersigned, I affirm that I have a serious medical condition that negatively affects my quality of life. I found, or am interested in ﬁnding, whether or not medical marijuana provides substantial relief and improvement in my condition. I hereby request a consultation by the physician for purposes of determining the appropriateness of medicinal marijuana treatment. The physician, staff, and representatives are addressing specific aspects of my medical care, and unless otherwise stated are in no way establishing themselves as primary care provider.

I realize I am paying KindHealth for an evaluation to assess my eligibility for the OMMU Registry. This evaluation may find my condition as not appropriate for Florida state certification. In the case you are not found eligible, there is no refund to you as our staff has performed its medical service appropriately. In short, I am paying KindHealth for the service, not a guaranteed eligibility.

Should an approval be made for my medicinal use of marijuana, I understand there is a renewal date specified by the physician depending on the condition. I understand that it is my responsibility to see the physician to assess the possible continuance of cannabis use beyond the term of the approval.

Flower
Given the potential adverse effects of smoking marijuana flower, the FL Board of Medicine requires doctors have patients use a vapor method of inhalation before advancing to flower. Purchase of a vape pen from the MMTC serves as ‘proof of vaping.’ If you then have vape pen related side effects, such as a cough, sore or harsh throat, only then can the ordering doctor add flower to your prescription. This purchase helps fulfill the requirement for both the state and doctor.

I have been given a copy of the KindHealth Notice of Privacy Practices for my review. By signing this form, I am consenting to KindHealth’s use and disclosure of my PHI in accordance with those terms. Furthermore, the undersigned, or anyone acting on my behalf, agree to hold the physician and his/her principals, agents, and employees, free of and harmless from any liability resulting from the use of medical marijuana.

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

KindHealth Assurance
KindHealth is committed to ensuring your health information is secure, and we protect your anonymity and privacy. We put physical, electronic and managerial procedures in place to safeguard and secure any data you provide us.

What is Protected Health Information?
Health information is any information about you, in any form that we either create, or receive from outside sources. This Notice of Privacy Practices refers to all health information as protected health information or “PHI”. Individually identifiable PHI includes health and demographic information collected from you which can reasonably be used to identify you.

PHI and the Law
Both state and federal law require KindHealth to limit the manner it uses or discloses information about a patient or a patient’s PHI in order to maintain your privacy. In addition, we are required to provide you with this privacy notice setting forth our legal duties and obligations, and your rights with respect to your PHI. All KindHealth care professionals and staff providing services in our practice are subject to this Notice of Privacy Practices and we may update the Notice from time to time, in which case we will prominently display the updated version.

Uses and Disclosures of Your PHI
This list is not all-inclusive. KindHealth uses any information you provide to us only in accordance with this Notice of Privacy Practices. KindHealth uses any information you provide to us only in accordance with this privacy statement. If you are an existing patient, you have already signed a consent. We will ask you to sign a consent if you are a new patient. The consent will allow KindHealth to use and disclose your PHI for your treatment, to obtain payment for the services we render to you and to assist us in our healthcare operations. We may use or disclose your PHI for your treatment or payments.

Treatments:
KindHealth may disclose and verify me as a patient to any law enforcement agency, my physician(s), Child Protective Services or any State approved dispensary.
Validate my status as a patient using the Medical Marijuana Use Registry online patient veriﬁcation system.
Our medical records personnel may review your chart to ensure proper placement of all lab and other tests results in your chart prior to your visit.
Our medical staff or physicians may communicate with laboratory or other testing facilities to review test results prior to your visit.
KindHealth staff and doctors may discuss your case among themselves or review your medical treatment with referring physicians or physicians to whom they have referred you for care.
Personnel in this office may discuss your medical information with a hospital or other healthcare facility treating you or we may discuss this information with another healthcare provider who is treating you at such a facility.
This practice may announce the names of patients in the waiting area, and others may hear your name.
This practice may leave VMs on your home answering machine, or send postcard or email appointment reminders.
This practice may disclose health information to a dispensary when we order a prescription for you.
This practice may send you information about other health-related benefits and services that may be of interest to you.
Payment Delinquency:
This practice may provide consumer-reporting agencies with credit information regarding your payment history.
This practice may provide information to collection agencies, our attorneys, or in a legal action for purposes of obtaining payment of delinquent accounts.

A printed copy of this form is available on request. I understand that KindHealth reserves the right to make changes to the terms of its Notice of Privacy Practices. I have read and understand the above Notice of Privacy Practices.

InOffice, Renew. New Pt.

In-Office. New patient. Card renewal.

Protected Health Information (PHI)

PATIENT ATTESTATION.

RELEASE of LIABILITY

NOTICE OF PRIVACY PRACTICES

KindHealth Assurance

What is Protected Health Information?

PHI and the Law

Uses and Disclosures of Your PHI

Treatments:

Payment Delinquency:

Sign up for 7-month visit reminders by text message (HIGHLY RECOMMENDED)

SMS TERMS of SERVICE

SMS PRIVACY POLICY