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MEDICAL REPORT FOR CAREGIVERS

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MEDICAL REPORT FOR CAREGIVERS

MEDICAL REPORT FOR CAREGIVERS State Form 45145 (R4 / 4-11) DEPARTMENT OF CHILD SERVICES INSTRUCTIONS: This report must be completed by a licensed physician.

https://forms.in.gov/Download.aspx?id=5163

Date added: October 25, 2012 - Views: 6

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Medical Marihuana Change Form - SOM - State of Michigan

MMP 3030 (Rev. 4/13) Michigan Medical Marihuana Registry. Caregiver Attestation . PROOF OF MICHIGAN RESIDENCY IS REQUIRED ...

http://www.michigan.gov/documents/mdch/Medical_Marihuana_Change_Form_3-27-09_272850_7.pdf

Date added: January 19, 2012 - Views: 22

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CAREGIVER INFORMATION FORM - Nebraska Judicial Branch

Caregiver Information Form, Page 2 Name of Caregiver: Case Number: Name of Child: 4. Current Status of Child’s Medical/Dental/General Physical ...

https://supremecourt.nebraska.gov/sites/supremecourt.ne.gov/files/forms/JC-caregiver-info-form.pdf

Date added: October 22, 2014 - Views: 1

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INSTRUCTIONS Massachusetts Caregiver Authorization Affidavit ...

INSTRUCTIONS Massachusetts Caregiver Authorization Affidavit Education and Health Care Form Who can use this form? If a child is living with you, a parent may give ...

http://www.mass.gov/courts/docs/courts-and-judges/courts/probate-and-family-court/upc/documents/massachusettscaregiverinstructions.pdf

Date added: May 16, 2014 - Views: 1

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MMMP - Caregiver Application Form - Maine.gov

Medical Use of Marijuana Program. Caregiver Application . SECTION 1: Caregiver Information New Applicant Renewal Adding ...

http://www.maine.gov/dhhs/dlrs/mmm/application-material/Caregiver-Application.pdf

Date added: November 23, 2011 - Views: 4

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Caregiver's Authorization Affidavit - California Courts - Home

Caregiver's Authorization Affidavit Use of this affidavit is authorized by Part 1.5 (commencing with Section 6550) of Division 11 of the California Family Code.

http://www.courts.ca.gov/documents/caregiver.pdf

Date added: May 23, 2012 - Views: 2

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Caregiver Application - New Mexico Department of Health

Caregiver Application Form filled out completely. It must be signed by the: O Patient O Caregiver, and ... Release of medical information to caregiver form 5.

http://www.nmhealth.org/publication/view/form/133/

Date added: November 22, 2014 - Views: 1

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Patient Information Change Form - Home: Department of Health

• Withdrawal from Medical Marijuana Program - Change in Debilitating Medical Condition ... form to add a caregiver will be mailed to you.

http://www.health.ri.gov/forms/request/MedicalMarijuanaPatientInformationChange.pdf

Date added: December 23, 2011 - Views: 4

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HOUSEHOLD MEMBERS Caregiver Medical (CHECK ONE) Provider ...

LDSS-4434-1 (Rev 5/2011) Front HOUSEHOLD MEMBERS ~DO NOT USE THIS FORM~ Caregiver Medical Statement (All Modalities) (CHECK ONE) Provider Substitute Volunteer

http://www.1ststepdaycare.com/forms/Caregiver%20Medical%20Statement.pdf

Date added: September 6, 2013 - Views: 1

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Medical Marijuana Program Designated Caregiver Application ...

Medical Marijuana Program Designated Caregiver Application Information ... and date the Medical Marijuana Caregiver Attestation. This form must be downloaded from the

http://www.azdhs.gov/medicalmarijuana/documents/caregivers/Designated_Caregiver_Application_Instructions.pdf

Date added: January 31, 2012 - Views: 2

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CAREGIVER REVIEW FORM

CAREGIVER REVIEW FORM Caregiver Name, ... Caregiver Signature Date Medical Provider Signature Date. pennsylvania DEPARTMENT OF PUBLIC WELFARE . Title: PA 1820.qxp

http://services.dpw.state.pa.us/oimpolicymanuals/manuals/bop/ca/PA_1820_(10-08).pdf

Date added: April 7, 2014 - Views: 1

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Medical Marijuana Transfer Authorization Form - Oregon.gov: Home

2/27/2014 Medical Marijuana Transfer Authorization Form I, , authorize ☐myself to transfer ☐ amount of usable marijuana ☐my caregiver ☐ immature plants

http://www.oregon.gov/oha/mmj/Documents/MM%20Transfer%20Authorization%20Form.pdf

Date added: April 7, 2014 - Views: 1

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Please Read Before You Start . . . What is VA Form 10-10CG ...

medical discharge, submit VA Form 10-10EZ "Application for Health Benefits ... for expedited processing; or, hand carry it to your local VA Medical Center Caregiver

http://www.va.gov/vaforms/medical/pdf/10-10CG.pdf

Date added: March 21, 2012 - Views: 115

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Medical Marijuana Identification Program Application/Renewal

MEDICAL MARIJUANA PROGRAM ... If you designate a primary caregiver on your application form, ... Written Documentation of Patient’s Medical Records form ...

http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdph9042.pdf

Date added: December 17, 2011 - Views: 27

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- Maine State Caregiver Designation Form

marijuana for medical purposes and have a debilitating condition authorized under Maine law. I have also provided ... This caregiver designation form is

http://www.maine.gov/dhhs/dlrs/mmm/application-material/Designation-Form.pdf

Date added: November 23, 2011 - Views: 4

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Caregiver Authorization Affidavit - Home Page - The Superior ...

1 CAREGIVER AUTHORIZATION AFFIDAVIT Caregiver Authorization Affidavit Instructions: completion of items 1-4 and the signing of the affidavit is sufficient to authorize

http://www.scscourt.org/forms_and_filing/forms/Sample_Caregiver_Affidavit.pdf

Date added: December 19, 2012 - Views: 6

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Application for Medical Marijuana Registry - Alaska ...

2 Rev. 06/2013 Primary Caregiver Application for Medical Marijuana Registry Please note that a Primary Caregiver is not required for an Applicant to be approved for ...

http://dhss.alaska.gov/dph/VitalStats/Documents/PDFs/MedicalMarijuana.pdf

Date added: February 1, 2013 - Views: 6

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2012 Parent-Spouse-Caregiver Medical Authorization

6919 Keystone Road Richmond, IL 60071 815-653-9374 Fax 815-728-1224 r [email protected] 1 2012 Parent-Spouse-Caregiver Medical Authorization.doc

http://www.mstrp.org/docs/2012Parent-Spouse-CaregiverMedical%20Authorization.pdf

Date added: March 26, 2013 - Views: 3

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Consent for Medical Treatment of Minors - Homepage | IU Health

Hospital provides this minor consent form and medical information questionnaire. ... medical care is necessary, the caregiver should take the consent form with the

http://iuhealth.org/images/whi-doc-upl/wm-MinorConsent-0412.pdf

Date added: December 27, 2012 - Views: 10

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Medical Marijuana Program Caregiver Change Form

STATE OF HAWAII DEPARTMENT OF HEALTH 4348 Waialae Avenue, #648 Honolulu, Hawaii 96816 Medical Marijuana Program Form CBD – 003 Caregiver Change

http://health.hawaii.gov/medicalmarijuana/files/2015/01/CBD-003cg-CBD-004cg-Combined-Change-and-Certification-01.06.15.pdf

Date added: January 31, 2015 - Views: 1

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CAREGIVER’S AUTHORIZATION AFFIDAVIT - Superior Court of ...

CAREGIVER’S AUTHORIZATION AFFIDAVIT ... another form of identification such as your ... upon a caregiver’s authorization affidavit to provide medical or ...

https://www.saccourt.ca.gov/forms/docs/pr-023.pdf

Date added: November 12, 2014 - Views: 1

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Patient and Primary Care Giver Registration Form

Complete the Primary Caregiver designation form on the back of this page. Your ... personal medical purposes of the patient upon the written or oral

http://www.peaceinmedicine.org/PDFs/PrimaryCareGiver.pdf

Date added: January 27, 2012 - Views: 17

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Medical Use of Marijuana Program Caregiver Application ...

Rev!9/2011! 3. I have enclosed the cultivation fee of $300 per patient for a total of $_____ 4. I have enclosed the $31.00 for a caregiver criminal background check.

http://www.maine-health.com/wp-content/uploads/2011/05/Caregiver-Application_Renewal-Form.pdf

Date added: September 6, 2013 - Views: 1

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Emergency Medical Consent Form - The Ultimate Child Care ...

©Nakali Consulting, Inc 2010 l Emergency Medical Consent Form EMERGENCY MEDICAL CONSENT FORM _____ has my permission to obtain

http://www.all-things-child-care.com/support-files/emergencymedicalconsentform.pdf

Date added: December 5, 2012 - Views: 146

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Medical Release Form - Virginia Youth Soccer Association

VYSA MEDICAL RELEASE FORM ... anesthesia, invasive surgery or any other form or kind of medical or surgical care (emergency or otherwise) for the player.

http://www.vysa.com/docs/registration/forms/VYSA%20Medical%20Release%20Form.pdf

Date added: November 30, 2011 - Views: 78

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Oregon Medical Marijuana Program (OMMP) Application Form

Page 1 of 2 Rev 10/11 Oregon Medical Marijuana Program (OMMP) Application Form SECTION A – Patient Information Complete all of Section A. You must provide a clear ...

http://public.health.oregon.gov/DiseasesConditions/ChronicDisease/MedicalMarijuanaProgram/Documents/application-form-instructions.pdf

Date added: July 7, 2012 - Views: 4

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Medical Marijuana Program APPLICATION/RENEWAL (Please Print)

State of California—Health and Human Services Agency Department of Health Services Medical Marijuana Program APPLICATION/RENEWAL (Please Print)

http://www.slocounty.ca.gov/Assets/PH/MMIC+Forms/DHS_9042_Application_Renewal_Form_English.pdf

Date added: September 29, 2012 - Views: 6

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Patient Access to Medical Marijuana in Washington State

caregiver to help with the medical use of marijuana. Patients and caregivers ... on the state medical marijuana registration form. 55 . Supply and Distribution Models .

http://www.doh.wa.gov/portals/1/Documents/2000/PatientAccess.pdf

Date added: May 24, 2013 - Views: 2

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Medication Record Form - Family Caregiver Alliance

Medication Record Form ... Show this form to doctors whenever you have an appointment. Bring this form with you to your pharmacy when you get a prescription filled.

https://caregiver.org/caregiver/jsp/content/pdfs/fs_medication_record_form.pdf

Date added: June 11, 2014 - Views: 2

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Caregiver Medical Form - Additional Bedroom for caregiver

The personal health information disclosed on this form will be used only for the purposes of determining an applicant’s eligibility for a modified unit or ...

http://www.torontohousing.ca/webfm_send/9465

Date added: July 7, 2013 - Views: 4

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CARETAKER AUTHORIZATION AFFIDAVIT - PCSAO

to consent to medical, psychological, or dental treatment for the child. ... Microsoft Word - HB 279 Caretaker Authorization Affidavit new form.docx Author:

http://www.pcsao.org/InTheNews/HB130%20CAA_Notice.pdf

Date added: October 22, 2012 - Views: 10

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7570 F AUTHORIZATION OF CAREGIVER CONSENT

7570 F AUTHORIZATION OF CAREGIVER CONSENT Use of this form is authorized by the New York State General Obligations Law. 1) I hereby state that I am the parent of the ...

http://district.auburn.cnyric.org/Student_Services/caregiver_form.pdf

Date added: May 15, 2012 - Views: 13

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Caregiver Medical Care Authorization

Caregiver Medical Care Authorization.pdf To download full version "Caregiver Medical Care Authorization.pdf" ... Caregiver Consent Form - Arizona State University

http://www.pdfslibforyou.com/caregiver-medical-care-authorization.pdf

Date added: January 31, 2015 - Views: 1

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Affidavit for Consent for Health Care for a Minor

consent to routine health care services. For non-routine health care services such as surgery, anesthesia, or emergency medical treatment, consent should be given as

http://www.wvdhhr.org/PDFs/AffidavitConsentMinor.pdf

Date added: April 5, 2012 - Views: 74

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Maine Medical Use Of Marijuana Program DESIGNATION FORM

y physician has certified that I have a condition that entitles me to participate in the Maine Medical Use of ... This caregiver designation form is

http://integr8health.com/wp-content/themes/Avada/docs/DHHS_Designation_Form.pdf

Date added: July 23, 2014 - Views: 1

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Hawaii Medical Use of Marijuana - Department of Public Safety

Hawaii Medical Use of Marijuana [Physician and Patient Information] ... out Section D of the registration form. Every primary caregiver shall be responsible for

http://dps.hawaii.gov/wp-content/uploads/2012/09/Physian-Information-Med-Marijuana-rev113011.pdf

Date added: March 16, 2013 - Views: 3

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Caregiver’s Affidavit - Home Page | Advocacy Inc.

Caregiver’s Affidavit Information NOTICE: This declaration does not affect the rights of the minor’s parents or legal guardian regarding the care, custody and ...

http://www.nmadvocacy.org/home/files/Caregiver%27s%20Affidavit.pdf

Date added: November 12, 2014 - Views: 1

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JV-290 Caregiver Information Form - California Courts - Home

CAREGIVER INFORMATION FORM To the current caregiver, ... Judicial Council of California JV-290 ... Current Status of Child's Medical, ...

http://www.courtinfo.ca.gov/forms/documents/jv290.pdf

Date added: November 8, 2012 - Views: 58

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Registration for Medical Marijuana Program Application

Instructions: Please complete all sections of this form in order to comply with the registration requirements of the Rhode Island Medical Marijuana Act.

http://www.health.ri.gov/forms/registration/MedicalMarijuanaNewApplication.pdf

Date added: December 20, 2011 - Views: 11

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Caregiver Medical Form - Royale Care Adult Foster Care Program

330 SW Cutoff, Suite 102, Worcester, MA 01604 Tel: (508) 926-8848/Fax: (508) 926-8858 Caregiver Medical Form Please check: Initial Update

http://www.royalecare-afc.com/uploads/5/4/0/8/5408053/afc_caregiver_medical_form.pdf

Date added: April 7, 2014 - Views: 1

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Caregiver Medical Certificate P-33B (pdf)

State of Connecticut Human Resources . Medical Certificate : Return to: Agency Name: _____ Attn: Human Resources Address:

http://das.ct.gov/HR/Forms/P-33B.pdf

Date added: April 30, 2012 - Views: 6

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Designated Caregiver Attestation Form - Arizona Department of ...

medical marijuana arizona department of health services program medical marijuana caregiver attestation i,_____, attest that:

http://www.azdhs.gov/medicalmarijuana/documents/caregivers/Caregiver_Attestation_Form.pdf

Date added: January 27, 2012 - Views: 3

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Caregiver Application Form - State of Illinois Home : Home

Page 1of 2 State of Illinois Illinois Department of Public Health P r intedb yAu h ofSa Il s P.O.#3115002 2M 9/14 IOCI 15-164 Illinois Medical Cannabis Pilot Program

http://www2.illinois.gov/gov/mcpp/Documents/Caregiver%20Application%20Form.pdf

Date added: January 29, 2015 - Views: 1

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MO DOH Medical Exam Report Form (Health Form)

mO 580-1879 (6-14) this form is to be kept on file at the child care facility BCC-4 missouri department of health and senior services section for child care regulation

http://health.mo.gov/safety/childcare/pdf/BCC-4.pdf

Date added: December 29, 2011 - Views: 5

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MMP 3502A Michigan Medical Marihuana Program www.michigan.gov ...

Patient Change Form Instructions 1. Make checks or money orders payable to: State of Michigan-MMMP

http://michiganholistichealth.com/forms/caregiver-attestation.pdf

Date added: November 30, 2012 - Views: 1

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Caregiver's Authorization Affidavit - Yuba County Superior Court

Caregiver's Authorization Affidavit (Use of this affidavit is authorized by Part 1.5 (commencing with Section 6550) of Division 11 of the California Family Code.)

http://www.yubacourts.org/sites/default/files/pdfs/CourtForms/FL09069.pdf

Date added: October 24, 2013 - Views: 6

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MEDICAL TREATMENT AUTHORIZATION AND CONSENT FORM

MEDICAL TREATMENT AUTHORIZATION AND CONSENT FORM The following form is designed for those situations where minors are unaccompanied by either parents or

http://wfa.net/minor.pdf

Date added: December 11, 2011 - Views: 1024

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Caregiver Court Information Form - Your Missouri Courts Home

CAREGIVER COURT INFORMATION FORM Child: Legal Case Number (if known): D.O.B ... Medical Provider Diagnosis Medications Required Follow-up (yes or no)

http://www.courts.mo.gov/hosted/circuit13/forms/JUV_CaregiverCourtInformation.pdf

Date added: September 6, 2013 - Views: 1

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CAREGIVER AUTHORIZATION FORM (Appendix 18)

CAREGIVER AUTHORIZATION FORM (Appendix 18) This form is intended to address the McKinney-Vento Homeless Assistance Act (P.L. 107-110) requirement that homeless ...

http://www.yourcharlotteschools.net/documents/registration/IndividualForms/18.pdf

Date added: July 18, 2013 - Views: 1