Recommending medical providers who do not use Utah's Electronic Verification System can certify a patient on this two-page paper form instead. It goes to a medical cannabis pharmacy, where a pharmacist enters it into EVS. The provider sets the qualifying condition from Appendix A, a card length shorter than the default year if wanted, dosage-form restrictions and the monthly purchase limit.
A recommending medical provider (MD, DO, APRN, PA or DPM) completes the whole form: provider and patient information, condition, card length, restrictions, monthly limit, and the acknowledgment and signature. The pharmacy completes only its verification box.
Download the current version from the source each time; forms change without notice.
Medical provider recommendation form for medical cannabis
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.
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To a medical cannabis pharmacy, not to the state. The patient can carry it to the pharmacy, or you can send it by encrypted email or secure fax. A pharmacist enters the certification into EVS and records whether it was verified in writing or verbally.
Cards are issued for 1 year. To issue a shorter card, mark 30 days, 3 months or 6 months on the form. The form, updated July 2026, includes Appendix A listing the qualifying conditions in Utah Code 26B-4-203, and one condition is chosen per form.