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Department of Health Use Only #ReceivedMedical Marijuana Dispensary Permit Application You may apply for one dispensary permit in this application for any of the medical marijuana regions listed below.
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What is your personal health information?
Your personal health information (PHI) includes any data about your health status, healthcare services you receive, and payment for healthcare services. This can encompass medical history, lab results, medication lists, and any personal identifiers.
Who is required to file your personal health information?
Healthcare providers, health plans, and healthcare clearinghouses are required to file your personal health information. Additionally, the patient or their authorized representative may also need to provide relevant information.
How to fill out your personal health information?
To fill out your personal health information, follow the specific forms provided by your healthcare provider. Ensure all sections are completed accurately, including your medical history, current medications, and any allergies.
What is the purpose of your personal health information?
The purpose of your personal health information is to assist healthcare providers in delivering appropriate care, to facilitate medical treatment coordination, and to ensure that billing and payment for services are processed accurately.
What information must be reported on your personal health information?
The information that must be reported includes your name, date of birth, contact information, medical history, allergies, current medications, and details of any past surgeries or hospitalizations.
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