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Form Dlara/mmp-502 - Instructions For Making Changes To A Medical Marihuana Registry Identification Card/form Dlara/mmp-050 - Change Form/etc.

DLARA/MMP-502 (Rev. 4/11)

Department of Licensing and Regulatory Affairs

Michigan Medical Marihuana Registry

P.O. Box 30083

Lansing, MI 48909

Instructions for Making Changes to a

Medical Marihuana Registry Identification Card

In order for the Michigan Medical Marihuana Program to process this Change Form you must submit the

following information together in one envelope:

 COMPLETE CHANGE FORM



REQUIRED: Complete Section A: PATIENT INFORMATION

o check the appropriate box if your address has changed.



REQUIRED: Complete Section B: CHANGES REGARDING PRIMARY CAREGIVER if you are:

o designating a new primary caregiver;

o removing your current caregiver; or,

o changing the address of your current caregiver.



REQUIRED: Complete Section C: PERSON ALLOWED TO POSSESS PATIENT’S MARIHUANA

PLANTS if you designated a new primary caregiver or removed your current caregiver.



REQUIRED for MINORS only: Complete Section D: CHANGE IN PARENT OR LEGAL

GUARDIAN WHO IS ALLOWED TO POSSESS MARIHUANA FOR MINOR PATIENT if there has

been a change in parent or legal guardianship for a minor who has been approved as a patient for

the Medical Marihuana Registry.



REQUIRED: Section E: PATIENT’S SIGNATURE & DATE – The Patient or, for a minor, a Parent

or Legal Guardian must sign and date the Change Form.

 $10.00 CHECK OR MONEY ORDER MADE PAYABLE TO “State of Michigan—MMMP”

 CLEAR COPY OF PATIENT’S CURRENT PHOTO IDENTIFICATION

 COMPLETED CAREGIVER ATTESTATION AND CLEAR COPY OF CAREGIVER’S CURRENT

PHOTO IDENTIFICATION (If designating a new caregiver.)

 IF NAME CHANGE IS SELECTED, CLEAR COPY OF SUPPORTING DOCUMENTS (I.E., MARRIAGE

LICENSE, DIVORCE DECREE, ETC)

 FOR MINORS ONLY: CERTIFIED OR TRUE COPY OF NEW LEGAL GUARDIANSHIP

DOCUMENTATION (If change in parent/legal guardian for minor.)

 FOR MINORS Only: DECLARATION OF PERSON RESPONSIBLE FOR A MINOR (If change in

parent/legal guardian for minor.)



The Declaration can be obtained from the Medical Marihuana Registry Application for Minors

application packet.

 SEND ALL OF THE ABOVE APPROPRIATE DOCUMENTS TOGETHER IN ONE ENVELOPE TO:

Department of Licensing and Regulatory Affairs

Medical Marihuana Registry

P.O. Box 30083

Lansing, MI 48909

If you have questions, please call the Michigan Medical Marihuana Registry Program at (517) 373-0395.

Form Dlara/mmp-502 - Instructions For Making Changes To A Medical Marihuana Registry Identification Card/form Dlara/mmp-050 - Change Form/etc.

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