New Hampshire's Therapeutic Cannabis Program requires this certification for every initial or renewal registry ID card. The provider attests to a provider-patient relationship built on a full assessment and certifies a qualifying condition: a listed diagnosis with a qualifying symptom (Box A) or a stand-alone condition (Box B). The patient mails it with the Patient Application, fee and proof of residency.
A New Hampshire physician, APRN or PA, another NH prescriber primarily responsible for the condition (dentist, podiatrist, optometrist, naturopathic doctor), or a Maine, Massachusetts or Vermont physician, APRN or PA primarily responsible for it completes every field. All need active DEA registration.
Download the current version from the source each time; forms change without notice.
Written Certification For the Therapeutic Use of Cannabis
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New Hampshire physicians (MD/DO), APRNs and PAs with active DEA registration. Dentists, podiatrists, optometrists and naturopathic doctors in New Hampshire may certify for a condition they are primarily responsible for, as may physicians, APRNs and PAs from Maine, Massachusetts or Vermont who are primarily responsible for the patient's condition.
The Program accepts a certification with an application for up to 6 months after the provider signs it. The registry card then runs 12 months by default, or 3 to 36 months as the provider selects. The certifying provider can lengthen a shorter certification with the Written Certification Extension, keeping the total within 3 years.
Not for an initial certification. Under He-C 401.06(b)(4), the full assessment includes an in-person physical examination, a medical and prescription history, review of tests, a documented diagnosis and a treatment plan. Telemedicine is allowed when the same provider recertifies the patient, and the form asks which applies.