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Orange County
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Health Care Agency
Public Health Services
MMIC

Forms
Medical Marijuana Identification Card Program

 

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Application / Renewal Form (DHS 9042) – English

Application / Renewal Form (DHS 9042) – English - Word DOC Application / Renewal Form (DHS 9042) – English - PDF file
Solicitud / Renovación Forma (DHS 9042-SP) – Español

Solicitud / Renovación Forma (DHS 9042-SP) – Español - Word DOC Solicitud / Renovación Forma (DHS 9042-SP) – Español - PDF file
Written Documentation of Patient's Medical Records (DHS 9044) – English

Written Documentation of Patient's Medical Records (DHS 9044) – English - Word DOC Written Documentation of Patient's Medical Records (DHS 9044) – English - PDF file
Documentación Escrita de los Expedientes Médicos del/de la Paciente (DHS 9044-SP) – Español

Documentación Escrita de los Expedientes Médicos del/de la Paciente (DHS 9044-SP) – Español - Word DOC Documentación Escrita de los Expedientes Médicos del/de la Paciente (DHS 9044-SP) – Español - PDF file
Authorization to Use and Disclose Protected Health Information (PHI) (F346-531 MMIC) – English

Authorization to Use and Disclose Protected Health Information (PHI) (F346-531 B) – English - Word DOC Authorization to Use and Disclose Protected Health Information (PHI) (F346-531 B) – English - PDF file
Application Appointment Checklist – English

Application Appointment Checklist – English - Word DOC Application Appointment Checklist – English - PDF file

 

 
 
  
   
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