Health Care Practitioner Registration

Logon Information

Email Address:*

Confirm Email Address:*

Password Requirements:

Passwords are case sensitive and have the following requirements:

8 characters or longer
both upper and lower case characters
at least one number or special character

Password:*

Confirm Password:*

Health Care Practitioner Information

Practitioner Type*

First Name*

Middle Initial*

Last Name*

Phone Number*

Medical License Number*

DEA Number*

Primary Clinic Address Information

Medical Group*

Primary Clinic Name*

Mailing Street Address*

Mailing Street Address 2*

Mailing Address City*

Mailing State*

Mailing Zip Code*

Clinic Phone Number*

Clinic Email Address*

Please check this box to review and accept the legal acknowledgement, consent, and disclosure statements.

Acknowledgement

Health Care Practitioner Registration Acknowledgment

I certify that I am a:

Doctor of Medicine authorized to practice medicine in Minnesota,
Minnesota licensed physician assistant acting with the scope of authorized practice, or
Minnesota licensed advanced practice registered nurse who has primary responsibility for the care and treatment of the patients’ qualifying medical conditions I will certify.

I also certify that my license to practice medicine is unrestricted. As a condition of participating in the medical cannabis patient registry system, I agree to notify the Office of Cannabis Management if my license becomes restricted or revoked or if I decide to discontinue care for patients in the medical cannabis program.

I agree to certify only patients with whom I have established a medical relationship. I will continue to treat all patients’ qualifying medical conditions I certify according to acceptable and prevailing medical practice standards.

I agree to report health records relating to the certification and ongoing treatment of all patients whose qualifying medical conditions I certify for the medical cannabis patient registry to and in a manner determined by the Office of Cannabis Management. I will comply with all requirements developed by the Office of Cannabis Management.

I understand patient registry information must be highly protected. Information I report to this registry are health records under Minnesota Statutes§ 144.291. Information in patient files maintained by the Office of Cannabis Management and a health care practitioner are private data on individuals as defined in the Minnesota Government Data Practices Act, Minnesota Statutes § 13.02, subdivision 12. This information may be used for purposes of complying with a request from the Minnesota Legislative Auditor or the Minnesota State Auditor in the performance of official duties. Therefore, I agree to:

access the registry information only to provide services for registered patients whose qualifying medical condition I have certified.
ensure all staff with access to the registry understand and comply with all patient privacy protections required by the medical cannabis patient registry.
take appropriate steps to ensure patient information is not released through unintentional or accidental disclosure.
take appropriate steps to ensure that my login names and passwords are available only to those authorized to access the patient registry, and
report immediately to the Office of Cannabis Management staff any privacy incident regarding the information in the patient registry of which I suspect or become aware. “Privacy incident” means any improper and/or unauthorized use or disclosure the patient registry information, improper or unauthorized access to or alteration of that information, and incidents in which the confidentiality of the information maintained in the registry has been breached.

I will not enter inaccurate or false information either knowingly or negligently in the medical cannabis patient registry.

I will report any suspected serious health effect caused by medical cannabis within 24 hours of my knowledge of the occurrence by completing a form on the Office of Cannabis Management website. A "serious health effect" is any unexpected or harmful physical or psychological reaction following the use of medical cannabis that results in death, admission to a hospital, or medical treatment beyond basic first aid or mental health care.

I have been informed of and understand that:

A health care practitioner who knowingly refers patients to a medical cannabis manufacturer or to a designated caregiver, who advertises as a medical cannabis manufacturer, or who issues certifications while holding a financial interest in a medical cannabis manufacturer is guilty of a misdemeanor and may be sentenced to imprisonment for not more than 90 days or by payment of a fine of not more than $1,000, or both.
A health care practitioner will be prohibited from certifying patients if they advertise:
- false or misleading statements about medical cannabis or the medical cannabis program.
- using colloquial terms to refer to medical cannabis, such as “pot,” “weed,” or “grass”.
- endorsement by the Office of Cannabis Management
- using images of cannabis in its plant form or leaf form or of cannabis-smoking paraphernalia; or
- with medical symbols that could reasonably be confused with symbols of established medical associations or groups.

A health care practitioner who knowingly falsely certifies a patient as suffering from a qualifying medical condition, who knowingly submits false information to the Office of Cannabis Management, or who knowingly violates any statute, rule, or the Office of Cannabis Management requirement with regards to the Medical Cannabis program may be removed from the patient registry.