NH Pediatric Care Provider Attestation (Cannabis)

Patients under 18 in New Hampshire's Therapeutic Cannabis Program must be certified by two providers, one of them a pediatric care provider under RSA 126-X:4, V(a). Providers specializing in pediatrics, family medicine or a pediatric subspecialty qualify without paperwork. Others, including some physician associates, use this one-page attestation to show they meet the definition.

Who completes it

The certifying provider for the minor completes the attestation with their license number, checks the basis on which they qualify, and signs it. The parent or guardian files it with the minor's application.

Submitting and payment

How to submit it
Give it to the minor's parent or legal guardian, or mail or fax it to the Therapeutic Cannabis Program yourself.

Good to know

  • A physician associate qualifies if their collaboration agreement, where RSA 328-D:3-b requires one, is with a pediatrics, family medicine or pediatric subspecialty physician, or if they work on a pediatric healthcare team.
  • A sole-practitioner PA, or any other provider, qualifies with extensive training and experience treating children from birth through young adulthood for physical, emotional and social needs.
  • Providers whose specialty is pediatrics, family practice or family medicine, or a pediatric subspecialty do not need this form.
  • It accompanies the Written Certification and the Minor Patient Application and does not replace certification of the minor's qualifying condition. Version 10/25.

Get the official form

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

Pediatric Care Provider Attestation

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.

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

When does a provider need the Pediatric Care Provider Attestation?

When serving as the required pediatric care provider for a patient under 18 without a specialty in pediatrics, family medicine or a pediatric subspecialty. That includes physician associates who qualify through their collaboration agreement or a pediatric healthcare team, and providers with extensive training and experience treating children through young adulthood.

How many providers must certify a minor in New Hampshire?

Two. A patient under 18 needs certifications from two providers, and one of them must be a pediatric care provider. The parent or guardian applies with the Minor Patient Application, and the attestation travels with that application or goes to the Program directly by mail or fax.