Patient Intake Form

Thank you for choosing Greenlight Wellness for your Medical Card Certification! Please complete your patient intake forms prior to your appointment. Call us at 877-420-5420 in case you have any questions

First Name *

Last Name *

Date of birth *

Street Address *

City *

State *

Postal code *

Phone *

Email *

Drivers Licence / State ID Number *

Do you have any diagnosed history of bi-polar disorder or schizophrenia? (this will not affect your ability to get a medical card) *

Yes

Are you assigning a Caregiver? *

Yes

Greenlight now offers weight loss management services. Would you like more information? *

Yes

Do we have permission to inform you regarding reminders, promotions, newsletters, etc. via email and text? *

Yes

How did you hear about our clinic? *

Which State are you in? *

Please Type in the Last four digits of your Social Security Number

Are you Opting For

1 Year card

2 Year Card

3 Year Card

Are you currently in any legal Trouble or probation? (this will not affect your ability to get a medical card) *

Yes

Are you interested in legal protection plan or letter of medical necessity? *

Yes

Have you Scheduled an Appointment? *

Yes

Date Of Appointment *

Time of Appointment

Permissions

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.

Signature *

Clear

Are you designating a caregiver? *

Yes

Caregiver legal name *

Caregiver DOB *

Caregiver Mailing Address *

Caregiver Phone *

Caregiver Email *

To Qualify to be a Caregiver:

Must be 21 or older
No felony conviction involving illegal drugs, or violence EVER, or any other felony within 10 years.

Followup Notice

It is required that all patients have a relationship with the doctor for medical marihuana. All patients are offered AN OPTIONAL follow up visit for $50. and are recommended to follow up within 6 months from initial visit. Telehealth appointments available for all follow up appointments.

(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]

Patient Sign *

Clear

HIPAA

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

Patient/Client Signature

Clear

Card/Photo Upload

Upload Photo ID / Driver's License

Caregiver Upload Photo ID / Driver's License

Medical Records: If you have any you'd like to upload

Upload Medical Records

Max 6 files

Medical Marijuana Card

Upload MMJ Card (front)