Fillable Oregon Medical Marijuana Program Application Form printable pdf download

Oregon Medical Marijuana Program

APPLICATION FORM INSTRUCTION and FEES

OMMP FEES ARE NON-REFUNDABLE

APPLICATION FEES

$200.00

No reduced fee proof is submitted and the Patient and Grower on the application are the same person.

$250.00

No reduced fee proof is submitted and the Patient and Grower on the application are different people.

$60.00

Current proof of SNAP/Oregon Food Stamps

receipt is submitted and the Patient and Grower on the

application are the same person.

$110.00

Current proof of SNAP/Oregon Food Stamps

receipt is submitted and the Patient and Grower on the

application are not the same person.

$50.00

Current proof of Oregon Health Plan

receipt eligibility is submitted and the Patient and Grower on the

application are the same person.

$100.00

Current proof of Oregon Health Plan

receipt eligibility is submitted and the Patient and Grower on the

application are not the same person.

$20.00

Current proof of Supplemental Security Income

receipt eligibility is submitted and the Patient and

Grower on the application are the same person.

$70.00

Current proof of Supplemental Security Income

receipt eligibility is submitted and the Patient and

Grower on the application are not the same person.

SNAP/Food Stamps: To qualify for the reduced fee, a copy of current proof of both the patient’s SNAP food stamp benefits and

Oregon residency (Oregon driver’s license or ID) must be provided at the time the patient submits an application.

OHP: To qualify for a reduced fee, a copy of current proof of both the patient’s Oregon Health Plan eligibility and Oregon

residency (Oregon driver’s license or ID) must be provided at the time the patient submits an application.

SSI: To qualify for a reduced fee, a copy of Supplemental Security Income monthly benefit receipt or eligibility for the current

Social Security Disability Income (SSDI) and

year must be provided at the time the patient submits an application.

do not qualify

Social Security Retirement benefits

for a reduced application fee.

MINORS

If the applicant is a minor (under age 18), the custodial parent or legal guardian with responsibility for health care

decisions must submit a notarized declaration and be listed as the Caregiver on the application. If the minor’s

Caregiver is also the minor’s Grower, the growsite registration fee is waived.

CRIMINAL HISTORY CHECK

According to ORS 475.304(6)(a), the Authority shall conduct a criminal records check under ORS 181.534 of any

person whose name is submitted as a Grower.

OHA/OMMP

Complete the application on the reverse side,

PO Box 14450

include the Attending Physician’s Statement,

Portland, OR 97293-0450

ID copies, check or money order, and mail to:

Until this application has been approved or denied by

The Oregon Medical Marijuana Act neither protects

the Oregon Medical Marijuana Program, a copy of

marijuana plants from seizure nor individuals from

these materials (along with proof of mailing or

prosecution if the federal government chooses to take

transmission) shall have the same legal effect as a

action against patients or caregivers under the federal

registration card. ORS 475.309(9)

Controlled Substances Act.

If you have any questions, need this document in an alternative format, or you would like a copy of the

rules or statutes, please contact the OMMP at 971-673-1234 (Monday – Friday, 11:00 am to 4:45 pm).

Do Not Fax

Rev 10/13

Oregon Medical Marijuana Program Application Form

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