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MEDICAL REPORT FOR CAREGIVERS - Indiana

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MEDICAL REPORT FOR CAREGIVERS - Indiana

Page 1 of 2 MEDICAL REPORT FOR CAREGIVERS State Form 45145 (R4 / 4-11) DEPARTMENT OF CHILD SERVICES INSTRUCTIONS: This report must be completed by a licensed physician.

https://forms.in.gov/Download.aspx?id=5163

Date added: October 25, 2012 - Views: 6

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Medical Marihuana Change Form - SOM - State of Michigan

MMP 3030 (Rev. 4/13) Michigan Medical Marihuana Registry. Caregiver Attestation . PROOF OF MICHIGAN RESIDENCY IS REQUIRED TYPE OR PRINT LEGIBLY

http://www.michigan.gov/documents/mdch/Medical_Marihuana_Change_Form_3-27-09_272850_7.pdf

Date added: January 19, 2012 - Views: 14

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Caregiver Application - Maine.gov

caregiver designation form for each patient for whom I grow medical marijuana. • I AGREE to return the caregiver designation form to the patient if the patient informs me that he or she no longer wants me to be his or her caregiver.

http://www.maine.gov/dhhs/dlrs/mmm/application-material/Caregiver-Application.pdf

Date added: November 23, 2011 - Views: 4

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Please Read Before You Start . . . What is VA Form 10-10CG ...

Instructions for Completing Application for Comprehensive Assistance for Family Caregivers Program. Please Read Before You Start . . . What is VA Form 10-10CG used for?

http://www.va.gov/vaforms/medical/pdf/10-10CG.pdf

Date added: March 21, 2012 - Views: 110

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HOUSEHOLD MEMBERS Caregiver Medical (CHECK ONE) Provider ...

LDSS-4434-1 (Rev 5/2011) Front HOUSEHOLD MEMBERS ~DO NOT USE THIS FORM~ Caregiver Medical Statement (All Modalities) (CHECK ONE) Provider Substitute Volunteer

http://www.1ststepdaycare.com/forms/Caregiver%20Medical%20Statement.pdf

Date added: September 6, 2013 - Views: 1

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Caregiver Medical Form - Additional Bedroom for caregiver

The personal health information disclosed on this form will be used only for the purposes of determining an applicant’s eligibility for a modified unit or additional bedroom and is collected under the authority of

http://www.torontohousing.ca/webfm_send/9465

Date added: July 7, 2013 - Views: 4

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MEDICAL MARIJUANA PROGRAM - Arizona Department of Health Services

MEDICAL MARIJUANA ARIZONA DEPARTMENT OF HEALTH SERVICES PROGRAM MEDICAL MARIJUANA CAREGIVER ATTESTATION I,_____, attest that: I have not been convicted of an excluded felony offense as defined in A.R.S. § 36-2801; I will assist ...

http://www.azdhs.gov/medicalmarijuana/documents/caregivers/Caregiver_Attestation_Form.pdf

Date added: January 27, 2012 - Views: 3

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Oregon Medical Marijuana Program (OMMP) - Public Health ...

Oregon Medical Marijuana Program (OMMP) Application Form ... There is no additional fee to designate a caregiver on your application form. If you remove your caregiver, it is your responsibility to tell the caregiver that he or she is no longer

http://public.health.oregon.gov/DiseasesConditions/ChronicDisease/MedicalMarijuanaProgram/Documents/application-form-instructions.pdf

Date added: July 7, 2012 - Views: 3

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**WE NO LONGER ACCEPT APPLICATIONS OR CHANGE FORMS IN PERSON ...

Completing the Form 1. Provide your name, medical marijuana registration number, date of birth and social security ... DO NOT USE this Change form to Add a New Caregiver If you wish to add a new caregiver please email [email protected] or call 401-222-3752. A

http://www.health.ri.gov/forms/request/MedicalMarijuanaPatientInformationChange.pdf

Date added: December 23, 2011 - Views: 4

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Caregiver's Authorization Affidavit - Judiciary of California

Caregiver's Authorization Affidavit Use of this affidavit is authorized by Part 1.5 (commencing with Section 6550) of Division 11 of the California Family Code.

http://www.courts.ca.gov/documents/caregiver.pdf

Date added: May 23, 2012 - Views: 2

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Medical Use of Marijuana Program - Maine

Page 2 of 3 Form 110103 Rev 12/2012 . SECTION 4: Caregiver Designation (Complete only if designating a Caregiver) Legal Name: Telephone No.: ( )

http://www.maine.gov/dhhs/dlrs/mmm/application-material/Designation-Form.pdf

Date added: November 23, 2011 - Views: 4

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Patient and Primary Care Giver Registration Form

Patient and Primary Care Giver Registration Form Please print clearly to avoid errors I _____, (patient name) am designating a Primary

http://www.peaceinmedicine.org/PDFs/PrimaryCareGiver.pdf

Date added: January 27, 2012 - Views: 17

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California Caregiver's Authorization Affidavit - California ...

Can I use the Caregiver’s Authorization form if the child’s parents object? No. ... Approving Medical Care Can I use a Caregiver’s Authorization Affidavit to approve medical or dental care for a child?

http://www.calindian.org/selfhelppdfs/SelfHelpCaregiver.pdf

Date added: February 23, 2012 - Views: 16

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Medical Marijuana Program Designated Caregiver Application ...

Medical Marijuana Program Designated Caregiver Application Information ... Print, sign, and date the Medical Marijuana Caregiver Attestation. This form must be downloaded from the ADHS website at http://www.azdhs.gov/medicalmarijuana/caregivers/

http://www.azdhs.gov/medicalmarijuana/documents/caregivers/Designated_Caregiver_Application_Instructions.pdf

Date added: January 31, 2012 - Views: 2

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Emergency Medical Consent Form - All Things Child Care

©Nakali Consulting, Inc 2010 l Emergency Medical Consent Form EMERGENCY MEDICAL CONSENT FORM _____ has my permission to obtain

http://www.all-things-child-care.com/support-files/emergencymedicalconsentform.pdf

Date added: December 5, 2012 - Views: 137

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Initial Registration As A - Rhode Island Department of Health

Instructions: Please complete all sections of this form in order to comply with the registration requirements of the Rhode Island Medical Marijuana Act.

http://www.health.ri.gov/forms/registration/MedicalMarijuanaNewApplication.pdf

Date added: December 20, 2011 - Views: 9

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Medical Release Form - VYSA

VYSA MEDICAL RELEASE FORM As the parent/legal guardian of _____, born _____ I hereby give my consent and permission for the player named below to be medically and/or

http://www.vysa.com/docs/registration/forms/VYSA%20Medical%20Release%20Form.pdf

Date added: November 30, 2011 - Views: 77

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Caregiver Registraion Form - Colorado

Colorado Department of Revenue Medical Marijuana Enforcement Division (MMED) Medical Marijuana Caregiver Cultivation Location Registration Form

http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobheadername1=Content-Disposition&blobheadername2=Content-Type&blobheadervalue1=inline%3B+filename%3D%22Caregiver+Cultivation+Registration+Form.pdf%22&blobheadervalue2=application%2Fpdf&blobkey=id&blobtable=MungoBlobs&blobwhere=1251836817789&ssbinary=true

Date added: July 7, 2013 - Views: 2

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Medical Marijuana Program APPLICATION/RENEWAL

Check your designation as a primary caregiver from the following list: I am the parent of the applicant or the person entitled to make medical decisions on behalf of the applicant.

http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdph9042.pdf

Date added: December 17, 2011 - Views: 23

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Caregiver’s Authorization Affidavit - Home Page - The ...

1 CAREGIVER AUTHORIZATION AFFIDAVIT Caregiver Authorization Affidavit Instructions: completion of items 1-4 and the signing of the affidavit is sufficient to authorize

http://www.scscourt.org/forms_and_filing/forms/Sample_Caregiver_Affidavit.pdf

Date added: December 19, 2012 - Views: 6

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CAREGIVER’S AUTHORIZATION AFFIDAVIT - Superior Court of ...

CAREGIVER’S AUTHORIZATION AFFIDAVIT ... enrollment of a minor in school and authorize school-related medical care. Completion of items 5 ... another form of identification such as your social security number or Medi-Cal number.

http://www.saccourt.ca.gov/forms/docs/pr-023.pdf

Date added: December 14, 2011 - Views: 26

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Medical Marijuana Transfer Authorization Form - Oregon.gov: Home

2/27/2014 Medical Marijuana Transfer Authorization Form I, , authorize ☐myself to transfer ☐ amount of usable marijuana ☐my caregiver ☐ immature plants

http://www.oregon.gov/oha/mmj/Documents/MM%20Transfer%20Authorization%20Form.pdf

Date added: April 7, 2014 - Views: 1

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Caregiver Medical Form - Royale Care Adult Foster Care Program

330 SW Cutoff, Suite 102, Worcester, MA 01604 Tel: (508) 926-8848/Fax: (508) 926-8858 Caregiver Medical Form Please check: Initial Update

http://www.royalecare-afc.com/uploads/5/4/0/8/5408053/afc_caregiver_medical_form.pdf

Date added: April 7, 2014 - Views: 1

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2012 Parent-Spouse-Caregiver Medical Authorization

6919 Keystone Road Richmond, IL 60071 815-653-9374 Fax 815-728-1224 r [email protected] 1 2012 Parent-Spouse-Caregiver Medical Authorization.doc

http://www.mstrp.org/docs/2012Parent-Spouse-CaregiverMedical%20Authorization.pdf

Date added: March 26, 2013 - Views: 3

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Alaska 's application for medical marijuana registry

2 Rev. 06/2013 Primary Caregiver Application for Medical Marijuana Registry Please note that a Primary Caregiver is not required for an Applicant to be approved for the Medical Marijuana Registry.

http://dhss.alaska.gov/dph/VitalStats/Documents/PDFs/MedicalMarijuana.pdf

Date added: February 1, 2013 - Views: 5

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CAREGIVER INFORMATION FORM - Nebraska Supreme Court

Caregiver Information Form, Page 2 Name of Caregiver: Case Number: Name of Child: 4. Current Status of Child’s Medical/Dental/General Physical Condition:

http://supremecourt.ne.gov/sites/supremecourt.ne.gov/files/forms/JC-caregiver-info-form.pdf

Date added: January 17, 2014 - Views: 1

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Medical Marijuana Program APPLICATION/RENEWAL (Please Print)

If you designate a primary caregiver on your application form, your primary caregiver must present ... Your doctor may use the Written Documentation of Patient’s Medical Records form (DHS 9044) to serve as the medical documentation.

http://www.slocounty.ca.gov/Assets/PH/MMIC+Forms/DHS_9042_Application_Renewal_Form_English.pdf

Date added: September 29, 2012 - Views: 6

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Medical Information - Indiana University Health

Hospital provides this minor consent form and medical information questionnaire. This form will be important, should your child become ill or injured while you are ... medical care is necessary, the caregiver should take the consent form with the child to the hospital or doctor.

http://iuhealth.org/images/whi-doc-upl/wm-MinorConsent-0412.pdf

Date added: December 27, 2012 - Views: 10

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7570 F AUTHORIZATION OF CAREGIVER CONSENT

7570 F AUTHORIZATION OF CAREGIVER CONSENT Use of this form is authorized by the New York State General Obligations Law. 1) I hereby state that I am the parent of the child(ren) named below and there are no court orders now in effect that would prohibit me

http://district.auburn.cnyric.org/Student_Services/caregiver_form.pdf

Date added: May 15, 2012 - Views: 13

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Caregiver’s Affidavit - Advocacy Inc

Caregiver’s Affidavit Information NOTICE: This declaration does not affect the rights of the minor’s parents or legal guardian regarding the care, custody and control of the minor.

http://www.nmadvocacy.org/home/files/Caregiver's%20Affidavit.pdf

Date added: December 22, 2012 - Views: 11

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JV-290 Caregiver Information Form - Judiciary of California

CAREGIVER INFORMATION FORM To the current caregiver, preadoptive parent, community care facility, or foster family agency caring for the child: ... Current Status of Child's Medical, Dental, and General Physical and Emotional Health Other (specify): current home for (specify): years months.

http://www.courts.ca.gov/documents/jv290.pdf

Date added: January 28, 2012 - Views: 3

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MMP 3030 (Rev. 6/13) Michigan Medical Marihuana Registry ...

MMP 3030 (Rev. 6/13) Michigan Medical Marihuana Registry Caregiver Attestation All fields below must be completed. (if applicable) OTHER NAMES USED BY CAREGIVER :

http://michiganholistichealth.com/forms/caregiver-attestation.pdf

Date added: November 30, 2012 - Views: 1

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Medical Use of Marijuana Program Caregiver Application ...

Rev!9/2011! 3. I have enclosed the cultivation fee of $300 per patient for a total of $_____ 4. I have enclosed the $31.00 for a caregiver criminal background check.

http://www.maine-health.com/wp-content/uploads/2011/05/Caregiver-Application_Renewal-Form.pdf

Date added: September 6, 2013 - Views: 1

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Change of Patient Records - Colorado

You may only change your caregiver or medical marijuana center one time per month. 8. ... A copy of the caregiver’s ID and form #MMR1012 Caregiver Acknowledgment are included, if the form has caregiver information. 10.

http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobheadername1=Content-Disposition&blobheadername2=Content-Type&blobheadervalue1=inline%3B+filename%3D%221003.pdf.pdf%22&blobheadervalue2=application%2Fpdf&blobkey=id&blobtable=MungoBlobs&blobwhere=1251933288092&ssbinary=true

Date added: January 5, 2013 - Views: 2

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MH-646 CAREGIVER’S 02/11/11 AUTHORIZATION AFFIDAVIT*

MH-646 CAREGIVER’S 02/11/11 AUTHORIZATION AFFIDAVIT* Page 1 of 2 ... Identification card), provide another form of identification such as your social security number or Medi-Cal number. ... medical or dental care, ...

http://file.lacounty.gov/dmh/cms1_159878.pdf

Date added: November 29, 2012 - Views: 2

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MEDICAL EXAMINATION REPORT FOR CAREGIVERS AND STAFF

MEDICAL EXAMINATION REPORT FOR CAREGIVERS AND STAFF patient may: have contact with children ... tb risk assessment form attached (required) a chest x-ray or appropriate written follow-up of a previous examination that indicates the individual is free of

http://health.mo.gov/safety/childcare/pdf/BCC-4.pdf

Date added: December 29, 2011 - Views: 5

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Patient/Caregiver Agreement - Michigan Medical Marijuana ...

Patient/Caregiver Agreement I _____ (the Patient)designate _____ (the Caregiver) to be my Primary Caregiver as defined in the Michigan Medical Marihuana Act of 2008 on this _____ day

http://michiganmedicalmarijuana.org/ccs_files/downloads/PatientCaregiverAgreement.pdf

Date added: May 4, 2012 - Views: 80

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INSTRUCTIONS Massachusetts Caregiver Authorization Affidavit ...

INSTRUCTIONS Massachusetts Caregiver Authorization Affidavit Education and Health Care Form Who can use this form? If a child is living with you, a parent may give you permission to make medical

http://www.mass.gov/courts/docs/courts-and-judges/courts/probate-and-family-court/upc/documents/massachusettscaregiverinstructions.pdf

Date added: May 16, 2014 - Views: 1

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Kinship Caregiving and Medical Consent Laws: An In-Depth Analysis

necessary, instigate the written caregiver affidavit form immediately after the child moves in with a relative; and • All physicians, nurse practitioners, and other health care professionals be

http://www.americanbar.org/content/dam/aba/migrated/child/PublicDocuments/summary_memo2.authcheckdam.pdf

Date added: June 14, 2012 - Views: 17

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State of Connecticut Human Resources Medical Certificate - CT DAS

Medical Certificate : Return to: Agency Name: ... Form #: P33B – Caregiver To be used by employees seeking family leave to care for a spouse, child, or . Revision Date: 2/2011. parent with a “serious health condition/serious illness”. AGENCY INSTRUCTIONS . This medical certificate is to be ...

http://das.ct.gov/HR/Forms/P-33B.pdf

Date added: April 30, 2012 - Views: 6

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**APPLICATION FORM** for Registry Identification Card PROOF ...

MMP 3030 (Rev. 6/13) Michigan Medical Marihuana Registry Caregiver Attestation PROOF OF MICHIGAN RESIDENCY IS REQUIRED TYPE OR PRINT LEGIBLY

http://www.michigan.gov/documents/mdch/Medical_Marihuana_RENEWAL_Packet_3-10_313245_7.pdf

Date added: January 20, 2012 - Views: 6

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MEDICAL TREATMENT AUTHORIZATION AND CONSENT FORM

MEDICAL TREATMENT AUTHORIZATION AND CONSENT FORM The following form is designed for those situations where minors are unaccompanied by either parents or

http://wfa.net/minor.pdf

Date added: December 11, 2011 - Views: 1006

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Form WH-385-V - U.S. Department of Labor

Page 1 CONTINUED ON NEXT PAGE Form WH-385-V Revised February 2013 Certification for Serious Injury U.S. Department of Labor or ... Military Caregiver Leave (Family and Medical Leave Act) OMB Control Number: 1235-0003 . Expires: 2/28/2015 .

http://www.dol.gov/whd/forms/wh385V.pdf

Date added: March 29, 2013 - Views: 5

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MEDICAL MARIJUANA REGISTRY REQUEST FORM - Nevada

MEDICAL MARIJUANA REGISTRY REQUEST FORM I am formally requesting a Medical Marijuana Cardholder/Caregiver Registry application. Included with this request is a check or money order in the amount of $25.00 made payable to Division of

http://health.nv.gov/MedicalMarijuana/MMRRequest.pdf

Date added: May 9, 2014 - Views: 1

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CAREGIVER REVIEW FORM

PA 1820 10/08 CAREGIVER REVIEW FORM Caregiver Name, Address and Telephone Number County/Record Number THIS SECTION MUST BE COMPLETED IF YOU ARE CARING FOR A FAMILY MEMBER WITH A DISABILITY

http://services.dpw.state.pa.us/oimpolicymanuals/manuals/bop/ca/PA_1820_(10-08).pdf

Date added: April 7, 2014 - Views: 1

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CARETAKER AUTHORIZATION AFFIDAVIT - PCSAO

to consent to medical, psychological, or dental treatment for the child. The child named below lives in my home, I am 18 years of age or older, ... card), provide another form of identification such as your social security number or medicaid number.

http://www.pcsao.org/InTheNews/HB130%20CAA_Notice.pdf

Date added: October 22, 2012 - Views: 10

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Affidavit for Consent for Health Care for a Minor

You have been unable to get a signed medical consent form from the child’s parent or legal guardian, ... caregiver’s home or a parent, guardian or legal custodian revokes his or her approval by written notification to the health care

http://www.wvdhhr.org/PDFs/AffidavitConsentMinor.pdf

Date added: April 5, 2012 - Views: 71

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The Program of Comprehensive Assistance for Family Caregivers

Caregiver Support Coordinators are available at every VA Medical Center to assist Veterans and their Caregivers with the application process. ... the application for the Caregiver Program (VA Form 10-10CG) will need to be completed.

http://www.caregiver.va.gov/pdfs/CaregiverFactSheet_Apply.pdf

Date added: December 14, 2011 - Views: 48

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Change in caregiver fingerprint forms - New Jersey

Change in caregiver fingerprint forms As of March 27, 2014, all new Medical Marijuana Program (MMP) caregivers will be required to use a new fingerprint form provided by

http://www.state.nj.us/health/medicalmarijuana/documents/change_carefingerprint_form.pdf

Date added: July 1, 2014 - Views: 1

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Please keep a copy of all application documents for your records.

Release of Medical Information to Caregiver Form . A caregiver is someone empowered by a patient to help the patient manage his/her medical care and medication. Completing this form gives our program permission to discuss issues

http://nmhealth.org/publication/view/form/133/

Date added: June 2, 2014 - Views: 1