Authorization to Release Medical Information

Patient Information

Patient Name

First Name *

Last Name *

Patient ID/License Number

Authorized Company/Agency Information

Name of Authorized Company/Agency

Name of Contact Person at the Company/Agency

Phone Number of Contact Person at the Company/Agency

Email of Contact Person at the Company/Agency

Please list the information needed:

Confirm status as a MCA-registered patient

Confirm provider certification as a MCA-registered patient

Copy of MCA-issued Patient Identification Card

Purchase history (please state time frame MM/YY-MM/YY)

Other (please describe)

Purchase history (please state time frame MM/YY-MM/YY)

Other (provide other reason for this request)

Please list the information needed. (What information is the patient requesting to be released to the recipient?)

Recipient Email ( A copy of this request will be delivered to the email address provided)

Patient Signature

First Name

Last Name

Choose how to sign

Draw Type

By signing this form, I authorize the Maryland Cannabis Administration to disclose the information selected on this form to the authorized party indicated on this form. I acknowledge that I may at any time revoke this authorization by submitting a request for revocation in writing. If not previously revoked, this authorization will terminate one year after the date I sign this authorization.