(1) The physician has reviewed the patient’s relevant medical records and completed a full assessment of the patient’s medical history and current medical condition, including arelevant, in-person, medical evaluation of the patient.

(2) The physician has created and maintained records of the patient’s condition in accord with medically accepted standards.

(3) The physician has a reasonable expectation that he or she will provide follow-up care to the patient to monitor the efficacy of the use of medical marihuana as a treatment of the patient’s debilitating medical condition.

(4) If the patient has given permission, the physician has notified the patient’s primary care physician of the patient’s debilitating medical condition and certification for the use of medical marihuana to treat that condition.

These criteria are used both by physicians in the practice of recommending medical marihuana to qualifying patients, and in the interpretation of eligibility for the legal protections of the Act by judges, prosecutors, and ultimately jurors, when determining if the patient or caregiver being prosecuted is qualified to use the Affirmative Defense. Inmost cases that lead to patient or caregiver arrest, the Affirmative Defense is the only way to force the courts to reach a reasonable decision.

Please call or email to schedule your follow up visit within 6 months of your initial visit.
877.420.5420 [email protected]

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in the office.

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:

1) Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.

2) It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.

3) The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.

4) You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.

5) You agree to bring any concerns or complaints regarding privacy to the attention of the office manger or the doctor.

6) Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.

7) We agree to provide patients with access to their records in accordance with state and federal laws.

8) We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.

9) You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward

Payment is due at the time of your appointment. If you choose to pay by credit card we need your permission to take the card over the phone. I give permission to Glow Services, DBA Greenlight Wellness to charge my credit card for the appointment fee on my appointment date if I choose to pay with a credit card.

I, hereby attest that I have a serious medical condition that adversely affects my quality of life. I am requesting a license for the use of medical marijuana as medication. I assume full responsibility for any and all risk for this action. There may be other additional risks not addressed herein, I assume full responsibility for any harm to me and or other individuals as result of my use of medical marijuana. I hereby grant the release of medical records to GL’S Consulting Service, LLC if they request them for additional evaluations. I, the undersigned, hereby requested a consultation by the physician for the purposes of determining the appropriateness of medical marihuana treatment. The physician, staff and representatives are addressing specific aspects of my chronic conditions for medical care, and unless otherwise stated, are in no way established as the primary care provider. I understand that this is my responsibility to see the physician to assess the possible continuance of medical marijuana use beyond the term of approval. Today’s consultation establishes a bona fide relationship with the Doctor. Furthermore, I the undersigned, my heirs, assigns or anyone acting on my behalf of the physician and his/her principals, agents, representative and employee, free of and harmless from any liability resulting from the use of medical marihuana. These are my personal representations’ and warranties with respect to my illness and my desire to seek a physician’s consult for medical marijuana evaluation.