Illinois Medical Cannabis Pilot Program Physician Written ... 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Qualifying Patient Information' section. Enter the patient's first name, middle name, last name, home address, date of birth, gender, and ZIP code clearly.
3. Next, complete the 'Physician Information' section. Provide your first name, middle name, last name, office address, telephone number, email address, and both your Illinois Physician License Number and Controlled Substances License Number.
4. Indicate how long the patient has been under your care and the date of their in-person medical examination related to this certification.
5. In the 'Debilitating Medical Condition' section, check all applicable conditions that apply to the patient. Ensure accuracy as this is crucial for their application.
6. Finally, review the 'Attestations' section. Sign and date the form to certify that all information provided is true and correct before giving it to the patient.

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