CERTIFYING PROVIDER COMPENSATION APPLICATION 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)

The Commission will consider each compensation request on a case-by-case basis. During the review process, MMCC staff may contact the applicant to request additional information/documentation that the Commission requires to assess whether the proposed compensation is permissible under COMAR 10.62.03.02.

Name of Certifying Provider *

Name of Practice *

MMCC Registration # *

What type of provider are you?

Physician

Dentist

Podiatrist

Nurse Practitioner

Certified Nurse Midwife

IS YOUR PRACTICE LOCATION ALSO YOUR MAILING ADDRESS?

Yes - Practice Location is Mailing Address

No - Mailing Address is Different

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 paid; COMAR 10.62.03.02(B)(1)

I am requesting compensation from a:

Dispensary

Grower

Processor

Name of Dispensary

Name of Grower

Name of Processor

Type of Compensation

Promotion

Referral

Recommendation

Advertising

Subsidized Rent

"Upload supporting documentation of compensation agreement and/or a copy of the expected compensation (e.g. promotional material, recommendation, referral, advertisement, subsidized rent agreement, or anything else of value you are expecting to receive as compensation)."

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Specific Amount/Value of Compensation

The Services for Which Compensation Will Be Paid

Any additional information/details about this request? (e.g. duration, location, and/or purpose of request)

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.

Enter your email address here if you would like a copy of this submission.

First Name

Last Name

Choose how to sign

Draw Type

By signing this, you are attesting that the compensation does not violate the Maryland Medical Practice Act or the Patient referral laws.