Rev 03/2022
For New Patient Applications and Renewals
Keep a copy of all application documents for your records including your Arkansas ID
⧠ Patient Registry Application form filled out completely and accurately.
⧠ Physician Written Certification Form filled out completely by an Arkansas licensed medical physician or
osteopathic physician (DO). A new form is needed each time you renew. This form must be received by the
Arkansas Department of Health within thirty days of the physician’s signature. If a caregiver is needed, the form
must indicate that the patient is physically disabled or a under 18; caregivers must apply separately and pay a
separate fee.
⧠ A current copy of the front of your Arkansas Driver’s License or State ID issued by the Department of Motor
Vehicles PLEASE MAKE SURE IT IS CLEAR AND VISIBLE.
⧠ Check or money order for $50 for the non-refundable fee. Payment should be made payable to ADH. DO NOT
MAIL CASH.
Mailing Address: Arkansas Department of Health
4815 West Markham, Slot 50
Little Rock AR, 72205
Application processing time is up to 14 working days from the date we receive your application and
payment.
Website: https://www.healthy.arkansas.gov/programs-services/topics/medical-marijuana
Telephone Number: 501-682-4982 or toll-free at 1-833-214-8619. We are open Monday through Friday from 8:00 a.m.
to 4:30 p.m. except for state holidays.
PLEASE PRINT CLEARLY. Ensure all forms are complete. Incomplete applications or applications with errors will be returned to
applicant. All forms must have the original signatures. Illegible applications may delay processing
Note: Applying online is easy. Please visit https://mmj.adh.arkansas.gov/ to apply online.
Arkansas Medical Marijuana Program
Qualifying Patient Checklist
Rev 03/2022
Arkansas Department of Health
Medical Marijuana Registry Patient Application
for new applications and renewals
To apply online visit https://mmj.adh.arkansas.gov
Patient Information
First Name
Middle Name
Last Name
Area code &
Phone
#
E
-
mail
Mailing Address Check if homeless
Street Number and Street (or PO Box)
Unit Type (Apt, Unit, Suite,
etc.)
Unit Number
City
State
Zip
County
Residence Address (If different from mailing address)
Street Number and Street (or PO Box)
Unit Type (Apt, Unit, Suite, etc.)
Unit Number
City
State
Zip
County
Patient
Identifiers
Date of Birth
(mm
/dd/
yyyy)
Arkansas
DL or ID number
ID Expiration
(mm/dd/yyyy)
Sex
Race
Last 4 digits of social
security
Yes No Are you an active-duty member of the Arkansas National Guard or the United States military?
By signing, I, the patient
pledge not to divert marijuana to anyone who is not allowed to possess marijuana under the Arkansas Medical
Marijuana Amendment of 2016. (Must be signed by the parent/guardian if under 18)
Signature
Date
Print Name
Optional
Caregive
r(s)
Information
.
Required if the patient is under 18.
1
First Name
M
iddle Name
Last Name
DOB
2
First Name
M
iddle Name
Last Name
DOB
3
First Name
M
iddle Name
Last Name
DOB
The Physician Written Certification
MUST
be marked either under 18 or physically disabled before a caregiver application can be processed.
Caregivers must complete a separate Caregiver application packet and pay a separate fee.
Send this completed form along with:
1. A completed Physician Written Certification form
2. A copy of the front of your Arkansas Driver’s License or Dept. of Motor Vehicles issued Arkansas State ID
3. A $50 non-fundable check or money order payable to:
Arkansas Department of Health
4815 W Markham, Slot 50
Little Rock, AR 72205
Application processing time is 14 working days from the date we receive your application and payment. Incomplete applications
and applications with errors will be returned for corrections and will take longer.
Rev 03/2022
*Pursuant to Act 1112 of 2021, physician written re-certification assessments may be done via telehealth.
Arkansas Department of Health
Medical Marijuana Physician’s Written Certification
To apply online visit https://mmj.adh.arkansas.gov
Patient Information
First Name
Middle name
Last Name
Street Number and Street name (or PO Box)
Unit Type (Apt, Lot, Suite, etc)
Unit Number
City
State
Zip
County
Date of Birth (mm/dd/yyyy)
Under the age of 18?
□ Yes □ No
Physically Disabled?
□ Yes □ No
□
I hold a valid, unrestricted, existing license to
practice as a medical physician or osteopathic physician in Arkansas and have been issued
a registration from the U.S. DEA to prescribe controlled substances.
□
It is my professional opinion, after having complete
d
an assessment
*
of the patient’s medical history and current medical condition in
the course of a physician patient relationship, the patient has a qualifying medical condition identified below.
Select the qualifying medical condition(s). Handwritten conditions will not be accepted:
□
Cancer
□
Glaucoma
□
Positive status for human immunodeficiency virus/acquired immune deficiency syndrome
□
Hepatitis C
□
Amyotrophic lateral sclerosis
□
Tourette’s syndrome
□
Crohn's disease
□
Ulcerative colitis
□
Post
-
traumatic stress disorder
□
Severe arthritis
□
Fibromyalgia
□
Alzheimer’s disease
□
Cachexi
a
or wasting syndrome
□
Peripheral neuropathy
□
Intractable pain, which is pain that
has not responded to ordinary medications, treatment or surgical measures for more than six (6)
months
□
Severe nausea
□
Seizures, including without limitation those characteristic of epilepsy
□
Severe and persistent muscle spasms, including
without limitation those characteristic of multiple sclerosis
Issue Registry Card for:
□ 12 months □ Less than 12 months:
___
Months
___
Weeks
Physician Information
First Name
Middle Name
Last Name
Arkansas Medical License Number
Street Number
and Street name (or PO Box)
Unit Type (Apt, Lot, Suite, etc)
Unit Number
City
State
Zip
County
Phone
By
signing
below, I do hereby attest that this information is true, accurate and complete
Date
This form must be received by the Arkansas Department of Health with payment and a completed application within 30
days of the physician’s signature.
Parent/legal guardian/legal custodian of minor patient – REQUIRED if the patient is under 18
As the parent/legal guardian or custodian of this minor patient, I am aware of the diagnosis risks, benefits and consent to the
minor patient’s use of marijuana.
Signature
Date
Print Name
