Release of Information -
Medical Marijuana - Healthcare Provider
Your consent & understanding of our practices are important to us.
Who qualifies as a Healthcare Provider: Examples consist of but are not limited to: Primary Care Physician, Nurse Practitioner, Family Practice Doctor, Gastroenterologist, Pain Management Doctor, OBGYN.
When I need to complete this form: In preparation for my Medical Marijuana Certification appointment, If I am a regular patient seeking to add Medical Marijuana to my wellness plan.
Why we need this form: In order to confirm diagnoses of one of the qualifying conditions for Medical Marijuana, Dr. Jones requires consent to collaborate with your current Healthcare Provider.
How we use this form: The information provided below is utilized by Dr. Tracey Jones to connect with and gather applicable records and diagnoses from your current Healthcare Provider