Patient Change Form - State Of Michigan
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2MMP 3502A (Rev. 1/15)
Michigan Medical Marihuana Program
Patient Change Form
(517)284-6400
For Current Registry ID Card Holders Only
Patient Change Form Instructions
1. Make checks or money orders payable to: State of Michigan-MMMP
2. Keep a copy of all documents submitted for your records.
3. Mail Change Form and all required documentation (see below) in one envelope to:
Michigan Medical Marihuana Program
PO Box 30083
Lansing, MI 48909
Patient Change Form Checklist
• Name Change
• Adding a Caregiver
Legal documentation†
Change Form dated and signed by Patient*
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Change Form dated and signed by Patient
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Patient’s Proof of Michigan residency**
*
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Proof of Michigan residency**
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Check Patient or Caregiver in the Change Plant Possession section
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Check Patient Name Change section
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Change Form dated and signed by Caregiver *
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$10 Patient Fee
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Copy of Caregiver’s valid MI photo ID***
$10 Patient Fee
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• Address Changes
$25 Caregiver Fee
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Change Form dated and signed by Patient
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*
Proof of Michigan residency**
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• Changing a Caregiver
Check Patient Address Change section
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Change Form dated and signed by Patient*
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$10 Patient Fee
Patient’s Proof of Michigan residency**
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Check Patient or Caregiver in the Change Plant Possession section
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• Change of Plant Possession
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Change Form dated and signed by Caregiver *
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Change Form dated and signed by Patient
*
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Copy of Caregiver’s valid MI photo ID***
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Proof of Michigan residency**
$10 Patient Fee
☐
Check Change Plant Possession section
☐
$25 Caregiver Fee
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$10 Patient Fee
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• Removing a Caregiver
Change Form dated and signed by Patient
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*
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Proof of Michigan residency**
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$10 Patient Fee
•
Request Replacement Card
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Change Form dated and signed by Patient
*
Proof of Michigan residency**
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Check Request a Replacement Card section
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$10 Patient Fee
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† Certified court document supporting name change: ie. marriage/divorce decree, legal name change document valid MI driver license or
Michigan identification card, etc.
* If you are signing for a third-party you must submit proof of legal guardianship of a copy of a Medical Durable Power of Attorney with
signatory authority for the active caregiver. Submitted Change Forms must have original signatures.
** A copy of a valid MI driver’s license, MI identification card, or MI voter registration. Cannot accept expired photo IDs.
***A copy of a valid MI driver’s license or MI identification card. Cannot accept expired photo IDs.
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