Health Care Practitioner Certification Form Rev. 6.20 Page 1
IOWA DEPARTMENT OF PUBLIC HEALTH
For the most current information regarding this
application, medical cannabidiol laws in the state
of Iowa and more, see the official website:
https://idph.iowa.gov/omc
Office of Medical Cannabidiol (OMC)
MEDICAL CANNABIDIOL REGISTRATION CARD - HEALTH CARE PRACTITIONER CERTIFICATION
Step 1 – The patient’s health care practitioner completes this form, signs, dates it and returns to patient.
Step 2 – Patient or Caregiver submits this completed form with their application and required documents.
WE CAN NOT ACCEPT THIS FORM ALONE OR DIRECTLY FROM YOUR HEALTH CARE PRACTITIONER.
We accept electronic applications!
For online submission of registration applications go to https://idph.iowa.gov/omc
For paper applications, mail completed application and required materials to: Iowa Department of Public Health
ATTN: OMC 321 E. 12
th
Street Des Moines, IA 50319-0075
Please print clearly - Incomplete or unreadable health care practitioner forms may result in denial of application.
PATIENT INFORMATION
Name
(First, Middle, Last)
Permanent Iowa Address
(Street, Apt. #)
Address
(City, State, ZIP Code)
Phone/Email
(Phone number and email address)
PRIMARY CAREGIVER DESIGNATION
Patient or guardian completes this section only if a primary caregiver has been designated for a patient
Primary Caregiver means a person, who is a resident of Iowa or a bordering state, including but not limited to a parent or legal
guardian, at least eighteen years of age, who has been designated by a patient’s health care practitioner as a necessary caretaker
taking responsibility for managing the well-being of the patient with respect to the use of medical cannabidiol.
Patient Name
(First, Middle Initial, Last)
I, ___________________________________, (adult patient or guardian of minor), hereby authorize the following person to be my
designated primary caregiver for the purpose of managing my well-being related to the use of medical cannabidiol. I authorize this
caregiver to assist me in the transportation, storage and use of medical cannabidiol. This person will be responsible for applying
through a separate application form for their own Medical Cannabidiol Registration Card as my caregiver.
Designated
Caregiver
Caregiver Name
(First, Middle, Last)
Caregiver Permanent Address
(Street, Apt. #, City, State, zip)
Caregiver Mailing Address
(P.O. Box, Apt. #, City, State, zip)
Health Care Practitioner Certification Form Rev. 6.20 Page 2
HEALTH CARE PRACTITIONER CERTIFICATION
INSTRUCTIONS: The patient’s health care practitioner must complete this form. This should be submitted as a part of your
completed application to the Office of Medical Cannabidiol. Partial applications will not be accepted. The patient application must
be received by the Office of Medical Cannabidiol within 60 days of the physician’s signature date.
NOTE: THIS DOES NOT CONSTITUTE A PRESCRIPTION FOR CANNABIDIOL or MEDICAL MARIJUANA.
HEALTH CARE PRACTITIONER INSTRUCTIONS: Please print clearly. Incomplete or unreadable health care practitioner forms may
result in denial of an application. Answer all of the questions with information in the patient’s medical record.
Patient Name
(First, Middle, Last)
HEALTH CARE PRACTITIONER INFORMATION
Health Care Practitioner means an individual licensed under Chapter 148 to practice medicine and surgery or osteopathic medicine
and surgery, a physician assistant licensed under chapter 148C, an advanced practice registered nurse under chapter 152E, who is a
patient’s primary care provider or a podiatrist licensed pursuant to chapter 149.
Health Care Practitioner’s Name
(First, Middle, Last, Suffix)
Medical License Number
License State
(Must be licensed in Iowa)
License Type
(MD, DO, PA, ARNP, DPM)
Practice Address
(Street)
Practice Address
(P.O. Box, Suite #)
Address
(City, State ZIP Code)
Phone Number
Email Address
Medical Specialty (Oncology, Neurology, Pain Management, etc.)
PATIENT’S QUALIFYING DEBILITATING MEDICAL CONDITION CERTIFIED BY HEALTH CARE PRACTITIONER
INSTRUCTIONS: Please indicate with a P the PRIMARY debilitating medical condition which qualifies the patient for a Medical
Cannabidiol Registration Card to the left of condition below. Please mark to left of condition with an S any SECONDARY conditions.
Cancer with severe or chronic pain
Cancer with nausea or severe vomiting
Cancer with cachexia or severe wasting
Multiple sclerosis with severe and persistent muscle spasms
Seizures, including those characteristic of epilepsy
AIDS or HIV as defined in Iowa Code, section 141A.1
Crohn’s disease
Ulcerative colitis
Amyotrophic lateral sclerosis
*Any terminal illness with a probable life expectancy of under one year and severe or chronic pain (please see bottom of page 2)
*Any terminal illness with a probable life expectancy of under one year and nausea or severe vomiting (please see bottom of page 2)
*Any terminal illness with a probable life expectancy of under one year and cachexia or severe wasting (please see bottom of page 2)
Parkinson’s disease
Chronic pain
Severe, intractable autism with self-injurious or aggressive behaviors
Corticobasal Degeneration
Post-Traumatic Stress Disorder (PTSD)
* A Healthcare Practitioner who certifies a patient for a terminal illness must indicate the specific grams of THC per 90 days that they
are certifying the patient for on the ‘4.5g THC Waiver Form.’ The patient must submit this form to the Department with their
application. If the Healthcare Practitioner does not complete this form, a limit of 4.5g THC per 90 days will be set for the patient.
Health Care Practitioner Certification Form Rev. 6.20 Page 3
Patient Name
(First, Middle Initial, Last)
HEALTH CARE PRACTITIONER CERTIFICATION
INSTRUCTIONS: Please initial all sections. Failure to initial all sections may result in the denial of an application.
I have established a patient-provider relationship with the patient identified above.
_______
Initials
I am a primary care provider involved in the diagnosis or treatment of this patient’s debilitating medical
condition. “Primary care provider” means any health care practitioner involved in the diagnosis and
treatment of a patient’s debilitating medical condition.
_______
Initials
I have determined in my medical judgment that this patient whom I have examined and treated suffers
from a debilitating medical condition that qualifies for the use of medical cannabidiol under Iowa Code,
chapter 124E.
_______
Initials
I have provided this patient with the explanatory information provided by the Iowa Department of Public
Health (found on the Department’s website at this web address: https://idph.iowa.gov/omc ) on the
therapeutic use of medical cannabidiol and the possible risks, benefits, and side effects of the proposed
treatment.
_______
Initials
I agree to determine, on an annual basis, if the patient continues to suffer from a debilitating medical
condition and, if so, issue the patient a new certification of that diagnosis.
_______
Initials
I agree to otherwise comply with all requirements established by the Iowa Department of Public Health
pursuant to rule, and provide other information as requested.
_______
Initials
I understand that I may provide, but have no duty to provide, this written certification of debilitating
medical condition for the applicant patient.
_______
Initials
HEALTH CARE PRACTITIONER ATTESTATION
I designate the person(s) if named in the Primary Caregiver Section as Primary Caregiver(s) in relation to the patient to manage the
patient’s well-being with respect to the use of medical cannabidiol pursuant to the provisions of Iowa Code chapter 124.E.
I certify under penalty of perjury that the foregoing statements and all information provided by me on this certification are true and
correct. I understand the law provides severe penalties (fine and/or imprisonment) for the willful submission of known false
information. I understand this certification does not, by itself, provide authorization for the Medical Cannabidiol Registration Card
for the above named patient/and/or caregiver(s). All other required application documentation must be submitted with this form.
Health Care Practitioner
Signature
Date of
Signature
Opt in Statement: I hereby authorize the Iowa Department of Public Health to release my name and practice address to patients
seeking certification of a qualifying debilitating medical condition for purposes of obtaining a medical cannabidiol registration card.
I understand that by checking the opt in box below, my name and practice address will be provided to patients upon request. I
further acknowledge that I must notify the Iowa Department of Public Health, Office of Medical Cannabidiol in the event I choose
to withdraw this authorization at a future time.
Opt in selection (check this box and sign below if you are opting in)
Health Care Practitioner
Signature
Date of
Signature
