A certifying provider uses this one-page form to rescind, for cause, a written certification they issued under New Hampshire's Therapeutic Cannabis Program. The provider checks the reason: the patient no longer has a qualifying condition, should stop using cannabis, falsified information, did not follow the treatment plan, or another compelling reason. It rests on RSA 126-X:4, IX(b) and He-C 401.06(f).
The provider who issued the patient's Written Certification completes and signs the statement of withdrawal, with the patient's name and date of birth and the practice phone number; the patient has no section to fill in.
Download the current version from the source each time; forms change without notice.
Written Certification Withdrawal
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Complete the Written Certification Withdrawal form, check the reason (no qualifying condition, should discontinue, falsified information, did not adhere to the treatment plan, or another compelling reason) and sign it. Then mail or fax it to the Therapeutic Cannabis Program. The form cites RSA 126-X:4, IX(b) and He-C 401.06(f).
No. The certifying provider completes and signs the whole form and sends it straight to the Therapeutic Cannabis Program by mail or fax. It refers back to the Written Certification For the Therapeutic Use of Cannabis that the same provider signed for the patient's registry ID card.