When a Connecticut certifying physician concludes a patient should stop the palliative use of marijuana, this one-page form asks the Department of Consumer Protection (DCP) to decertify them. DCP then tells the patient, and any caregiver, that the certification is no longer in effect. The patient has 30 days from that notice to provide a new, valid certification before the registration is rescinded.
Only the patient's certifying physician may use it, entering their name, Connecticut medical license number and mailing address, the patient's name and date of birth, two yes-or-no answers and a brief statement explaining why, then signing and dating it.
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Physician Decertification Form
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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No. The form may be used only by the physician who certified the patient. If you have concerns about a patient certified by a different physician, DCP asks you to address them with that physician, who can decide whether to file a decertification.
DCP contacts the patient and any caregiver to say the certification is no longer in effect. The patient then has 30 days from receiving that notice to provide a new, valid physician certification; otherwise the registration is rescinded.
The form asks for a brief written statement explaining why you seek to decertify the patient, plus a yes-or-no answer on whether, in your professional opinion, the patient should discontinue palliative use of marijuana. You sign the form under penalty of law.