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Maryland Medical Cannabis Commission

reporting.mmcc@maryland.gov

849 International Drive, 4th Floor, Linthicum, MD, 21090, US

CERTIFYING PROVIDER COMPENSATION REQUEST FORM

IMPORTANT: A certifying provider may not receive compensation, including promotion, referral, recommendation, advertising, subsidized rent, or anything of value from a licensed grower, licensed processor, or a licensed dispensary unless the certifying provider submits an application to the Commission for approval for the compensation. COMAR 10.62.03.02(A) 

What type of provider are you?

Practice Location

IS YOUR PRACTICE LOCATION ALSO YOUR MAILING ADDRESS?

Mailing Address

Compensation Information

The application shall disclose: The specific type of compensation and specific amount or value of compensation and the services for which the compensation will be paidCOMAR 10.62.03.02(B)(1) 

I am requesting compensation from a:

Type of Compensation

Attestation

COMAR 10.62.03.02 (B) The application shall disclose: (2) An attestation that the compensation does not violate the: (a) Maryland Medical Practice Act, codified at Health Occupations Article, §14-101 et. seq., Annotated Code of Maryland; or (b) Patient referral laws codified at Health Occupations Article, §1-301 et. seq.,  Annotated Code of Maryland.

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