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Vermont Healthcare Professional Verification Form

Vermont's Medical Cannabis Program asks a healthcare professional to verify that the patient-applicant has a debilitating medical condition as defined by Vermont law. The form states that it is not a prescription for, or recommendation of, cannabis. It reaches the Cannabis Control Board before the patient's online application and must be signed within 6 months of submission.

Who completes it

A healthcare professional licensed as an MD, DO, ND, PA or APRN/NP in Vermont, New Hampshire, Massachusetts or New York completes the verification pages: patient information, license details, condition verification and the bona fide relationship questions. The patient applies online separately.

Submitting and payment

How to submit it
Upload it through your VisualVault provider portal account, or print it and mail, fax or email it to the Medical Cannabis Program before the patient submits the online application.

Good to know

  • Listed conditions (cancer, MS, HIV/AIDS, glaucoma, Crohn's, Parkinson's, PTSD, ulcerative colitis) qualify with severe, persistent, intractable symptoms; other chronic conditions qualify with cachexia, chronic pain, severe nausea or seizures.
  • A bona fide relationship needs at least 3 months plus a full assessment and in-clinic physical exam; exceptions include terminal illness, cancer, AIDS, hospice, a recent move, specialist referral and sudden onset.
  • Under CCB Rule 3.8, the program rejects verifications from providers affiliated with organizations whose exclusive or dominant service is verifications, or with a conflict of interest.
  • A professional who signed a verification may withdraw it at any time by sending the Board a signed statement.

Get the official form

Download the current version from the source each time; forms change without notice.

Healthcare Professional Verification Form

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

See how Vero Documents works

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Is Vermont's Healthcare Professional Verification Form a cannabis prescription?

No. The cover sheet says the form only certifies that a qualified provider has diagnosed the patient with a debilitating medical condition as defined by Vermont law, and that it is not a prescription for, or recommendation of, cannabis. The professional also certifies being in good standing with their licensing authority.

Can a New Hampshire or New York provider complete Vermont's verification form?

Yes. Vermont's definition of healthcare professional includes MDs, DOs, naturopathic physicians, PAs and APRNs licensed under substantially equivalent provisions in New Hampshire, Massachusetts or New York, and the form has checkboxes for those issuing states. The 3-month relationship and in-clinic examination questions apply the same way.