Change Of Information Form - Government Of The District Of Columbia printable pdf download

Government of the District of Columbia

Department of Health

Health Regulation & Licensing Administration

HANGE OF

NFORMATION

ORM

*Within fourteen (14) calendar days of any change in a patient’s name, address, caregiver, recommending

physician, or designated dispensary, the patient who has been issued a registration identification card shall

submit a completed change of information form.

*Within fourteen (14) calendar days of receiving notice of a patient’s change of name, address,

recommending physician, or designated dispensary, the patient’s registered caregiver shall submit a

written request for a new registration identification card using the change of information form.

: In the box at the top of the Change of Information Form, provide your name, date of birth,

NSTRUCTIONS

and registration number as it appears on your registration card. Check the box in the section that you would

like to change and enter the new information as required.

: There is no fee for the following changes:

EES

Change of patient or caregiver home address

Remove caregiver registration

Withdraw from the Medical Marijuana Program.

For all other changes, there is a $90.00 fee to replace the registration card. Registrants whose income is

equal to or less than two hundred percent (200%) of the federal poverty level may replace their cards for a

fee of $20.00. Fees may be paid by certified check, money order, or cashier’s check payable to the DC

Treasurer;

no personal checks.

PECIFIC

NSTRUCTIONS

Name changes- if you have a name change, you must enclose a copy of your certificate of marriage,

divorce decree, or court order which authorizes the name change.

Address changes-

You must provide at least one primary source (original) document, as listed

below, to satisfy proof of residency. Any one of the following documents will be accepted:

•

Utility bill (Water, Gas, Electric, Oil, or Cable) with applicant name and address, issued within the

last sixty (60) days

•

Telephone bill (no cell phone, wireless or pager bills acceptable) reflecting applicant's name and

current address, issued within the last sixty (60) days

•

Deed or settlement agreement in applicant’s name reflecting property address

•

Unexpired lease or rental agreement with the name of the applicant listed as the lessee, permitted

resident or renter (may be a photocopy)

•

DC Property Tax bill

•

Unexpired homeowner's insurance policy reflecting name and address

•

Letter with picture from Court Services and Offender Supervision Agency (CSOSA) or DC

Department of Corrections certifying name and residence

•

DC DMV Proof of Residency Form signed by the person owning the residence AND a copy of

this person's unexpired DC driver license or DC identification card AND one of the primary

sources listed above (i.e. Utility bill, telephone bill, etc.) in the person owning the residence’s

name

899 North Capitol Street, NE, 2

Floor, Washington, DC 20002 Email:

doh.mmp@dc.gov Website:

Change Of Information Form - Government Of The District Of Columbia

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