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INSTRUCTIONS FOR MEDICAL PROVIDERS

Written Certification Version 8/21 Certification INSTRUCTIONS Page 1 of 1 Lori A. Shibinette Commissioner Patricia M. Tilley Director STATE OF NEW HAMPSHIRE DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF PUBLIC HEALTH SERVICES THERAPEUTIC CANNABIS PROGRAM 29 HAZEN DRIVE, CONCORD, NH 03301-3857 603-271-9333 1- 800-852-3345 Ext. 9333 TDD Access: 1-800-735-2964 Email: WRITTEN CERTIFICATION For the Therapeutic Use of Cannabis Information about the Therapeutic Cannabis Program, including the law (RSA 126-X ), the rules (He-C 400), all required forms, and the MEDICAL Provider Information Sheet, is available on Program s website at: MEDICAL provider must complete ALL information on this Written Certification. Failure to complete this form in itsentirety will cause your patient s application to be incomplete and the Written Certification to be returned to the completed Written Certification to your patient to submit to the Program.

(4) A physician or APRN licensed to prescribe drugs to humans under state licensing laws in Maine, Massachusetts, or Vermont, and who is primarily responsible for the patient’s care related to the patient’s qualifying medical condition. All providers must have an active registration from the US DEA to prescribe controlled substances. 6.

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