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Michigan MMP 3501: Physician Certification Form

A Michigan Medical Marijuana Program registry card requires a certification from a Michigan physician that the patient has at least one qualifying debilitating condition. The one-page form, page 3 of the adult packet, lists conditions in Categories A to C, and the physician attests to a bona fide physician-patient relationship, a full assessment including a relevant medical evaluation, and likely therapeutic or palliative benefit.

Who completes it

A medical doctor or doctor of osteopathic medicine with an active Michigan license completes Sections A (physician information and 10-digit license number) through D (certification and signature). The patient completes the separate application form.

Submitting and payment

How to submit it
Adults applying without a caregiver can apply online; others mail the packet with the application, proof of residency and fee. The certification must be signed and dated within six months of when the program receives it.
Who pays
The patient pays the program's registry application fee; the form sets no fee for the physician's evaluation.

Good to know

  • Category A lists conditions such as cancer, glaucoma, HIV, hepatitis C, ALS, Crohn's disease and agitation of Alzheimer's; Category B covers conditions producing cachexia, severe chronic pain, severe nausea, seizures or persistent muscle spasms.
  • Category C includes PTSD, OCD, arthritis, rheumatoid arthritis, spinal cord injury, colitis, IBD, Parkinson's disease, Tourette's syndrome, autism, chronic pain and cerebral palsy. At least one box must be checked.
  • Any white-out or change on the application or the physician certification results in denial, so a correction means completing a fresh form.
  • Renewals require recertification by a physician, and patients keeping or adding a caregiver must apply by mail rather than online.

Get the official form

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

Physician Certification Form (Michigan Medical Marijuana Program)

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.

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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.

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Frequently asked questions

Who can sign the Michigan medical marijuana physician certification?

Only a medical doctor (MD) or doctor of osteopathic medicine and surgery (DO) with an active Michigan license, entered as a 10-digit license number. The physician attests to compliance with the Michigan Medical Marihuana Act and its rules and to a bona fide physician-patient relationship.

How long is the Michigan physician certification valid for an application?

The application and physician certification must be signed and dated within six months of the date the Michigan Medical Marijuana Program receives them. Applicants should use the most current packet posted by the program.

What must the physician attest to?

That the information is accurate, that they have a bona fide physician-patient relationship with the patient, that they completed a full assessment of medical history and current condition including a relevant medical evaluation, and that the patient is likely to receive therapeutic or palliative benefit for the certified condition or its symptoms.