Patient/Caregiver Registration Inactivation Request Form

Please note that once the account has been inactivated, it cannot be recovered/reactivated. In order to become a patient or caregiver again a new application would need to be submitted, including the non-refundable registration fee ($25).

If you have a physical ID card, you must send it back to the MCA at the following address:

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

I am requesting to inactivate the following registration(s):

Date of Request

Patient Information

Patient ID/License Number

Patient Type

Patient's Last 4 Digits of Social Security Number (SSN)

Patient's Date of Birth (DOB)

Caregiver Information

Caregiver ID/License Number

Caregiver's Last 4 Digits of Social Security Number (SSN)

Caregiver's Date of Birth (DOB)

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

Reason for Inactivation

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First Name

Last Name

Choose how to sign

Draw Type

I authorize for the Maryland Cannabis Administration to inactivate my Patient/Caregiver registration.