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1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section 1, entering the patient's full legal name, date of birth, and telephone number. Ensure all information is printed legibly.
3. Proceed to Section 2, where the health care professional must provide their full name, office mailing address, city, state, zip code, and telephone number.
4. In Section 3, input the health care professional's license number and select the issuing state from the options provided.
5. Complete Section 4 by selecting the appropriate licensure category that applies to the health care professional.
6. In Section 5, confirm whether the patient has a debilitating medical condition by checking 'Yes' or 'No'. If 'Yes', complete Section B with specific diagnoses and symptoms.
7. Section 6 requires confirmation of a bona fide health care professional-patient relationship. Answer each question truthfully.
8. Finally, ensure that the health care professional signs and dates the form in Section 7 before submission.

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