Maine Medical Marijuana Certification Checklist
Stephen Blythe, D.O.
P.O. Box 411388
Melbourne, FL 32941
What is needed:
1. Certification questionnaire completed and returned.
2. Consent signed and returned.
3. Provide a working phone number where you can be reached in the evening.
Make sure that you have Voice Mail turned on and that your mailbox is not
full so that I can leave a message if I do not reach you.
4. If you have a good high-speed internet connection and can do Skype,
provide me with your Skype address. We will touch base via phone to set
up a time to Skype.
5. Make sure you provide me with a good address. Your certificate will be sent
via Priority Mail after the consultation as long as you are qualified.
6. $165– a personal check is acceptable, but I will wait for it to clear before
calling you. A cashier’s check or money order may be faster. I also can
accept credit cards now, but they cannot be gift cards that do not have an
expiration date and a 3-digit security code on the back. If you mail a money
order or cashier’s check consider getting insurance with tracking at the post
office. We can run your credit card when we do the consultation.
7. After I receive your paperwork and before I call you, you will receive in the
mail a DVD with a 45-minute video presentation about the Maine Medical
Marijuana Program and a book entitled: “Medical Marijuana: A Patient’s
Guide” which I wrote. Both of these contain all of the information which
used to be included in the 45-minute consultations which I provided at the
office in Ellsworth. You MUST either watch the DVD (on a computer or
regular DVD player) OR read through the book before we do the
consultation.
I want to make sure that you are qualified before you spend your money and our
time on a consultation. For this reason I need to have either copies of medical
records which document your qualifying condition OR a referral form completed
by your current provider. See the attached medical records and referral sheets.
Stephen L. Blythe, D.O.
P.O. Box 411388
Melbourne, FL 32941
Medical Marijuana Questionnaire
Name: ____________________________________________
Date of Birth: __________________
Address: __________________________________________
Phone: _______________________
__________________________________________________
Condition for which you wish certification/recertification:
Multiple Sclerosis, ALS, or other neurodegenerative disease
HIV/AIDS
Hepatitis C
Fibromyalgia
PTSD
Glaucoma
Chronic back pain or other chronic musculoskeletal pain
Neuropathic pain (diabetic or post-herpetic neuropathy, other)
Crohn’s Disease
Alzheimer’s Disease with agitation
Cancer or cancer treatment causing nausea, pain, or weight lost/wasting
Other intractable pain, muscle spasm, nausea, or wasting syndrome
Is this a recertification? ___ No ___ Yes
Treating Physician Name: _____________________________
Phone: ________________________
Address: ___________________________________________
Fax: __________________________
___________________________________________________
Does your treating physician accept that you will be using medical marijuana? __ Yes
__ No
Please list what medications and other treatments you are currently using for the above problem:
What treatments have you used in the past for this problem that did not help or that caused side
effects?
What other medical conditions do you have?
Diabetes
High blood pressure
Heart Disease
Cancer
Kidney Disease
Liver Disease
COPD, emphysema, or asthma
Other (list below)
What other medications are you currently using?
What other health conditions or surgeries have you experienced in the past?
Please list any drug, food, or other allergies (including hay fever type allergies):
Have you ever used marijuana? __ Yes
__ No
If so, did you have any problems with it? __ Yes (describe below)
Have you used marijuana for the above problem? __ Yes
__ No
__ No
If so, what has been your experience?
Do you currently use tobacco? __ Yes
__ No If no, have you ever? __ Yes
__ No
If yes, what form, how much, and how old were you when you started? If no, what form, how much,
and when did you start and stop?
Signed: __________________________________ Date: _______________________
What “Medical Records” are Required for an MMJ Consultation:
Medical records documenting your qualifying condition are required for all initial certification
and any recertification unless I did the original certification.
Dr. Blythe does NOT diagnose your medical condition, and therefore requires that you submit
either a referral from your regular provider (who HAS diagnosed and is treating the qualifying
condition) or else medical records documenting that such diagnosis has been done. A referral
form is generally sent with your paperwork.
A Referral Form may be completed, signed, and faxed to Dr. Blythe by your provider. A
“provider” may be a licensed counselor, psychologist, or psychiatrist (if the diagnosis is PTSD),
or may be a primary care physician (or Nurse Practitioner). In addition, a chiropractor may send
a referral form if you have been getting chiropractic treatments on an ongoing basis for chronic
pain.
Military Discharge Papers that indicate that you have partial or total disability from PTSD will
be sufficient to document PTSD as a qualifying condition.
Medical Records means office or hospital doctor’s notes which document the diagnosis and
treatment of a qualifying condition. You may tell me that you have a painful condition, but the
legal requirements of the Maine MMJ Program defines “chronic intractable pain” as pain that
has not responded to conventional treatment. If you have not sought treatment for the painful
condition, you do not qualify. I am sorry if you “don’t like doctors”, or “don’t want to take pills”
– you still have to have your painful condition evaluated and you have to have sought
treatment to qualify. If you cannot afford a visit to a physician, then you most likely cannot
afford medical marijuana.
If you would like a detailed evaluation by a physician who also certifies patients for medical
marijuana, please consider scheduling an appointment with Dr. Dustin Sulak in Manchester,
Maine at 207-512-8633.
X-rays alone do NOT qualify as adequate documentation of chronic pain. And certainly an x-ray
report from twenty years ago showing that you had a broken ankle does not qualify. The only xray report which would qualify you is a lumbar (back) or cervical (neck) MRI which says
“moderate to severe” spinal stenosis or nerve impingement. That generally corresponds to
painful deterioration. “Mild to moderate” deterioration is something seen in most MRI’s as we
get older and has very little correlation to pain. If in doubt send me the records and I will let
you know if they are sufficient to qualify you.
My FAX NUMBER IS: 877-220-0488
Stephen L. Blythe, D.O.
Telemedicine services for Maine Medical Marijuana Patients
P.O. Box 411388
Melbourne, FL 32941
Consent for Treatment
I, _________________________, hereby consent for evaluation and treatment by Dr. Stephen
Blythe via a telemedicine consultation using internet services or via telephone conference. This
consent will remain valid unless cancelled in writing.
I understand that all treatments or even lack of treatment carries certain risks and benefits. I
understand that Dr. Blythe will help me to understand the possible benefits and commonly
encountered risks of medical marijuana if I am a candidate for certification. It is my
responsibility to request further information if there is anything about the risks and benefits that I
do not understand. I agree to be truthful about any medical conditions, risks, or exposures that I
may have now or may have had in the past, and will stop using medical marijuana promptly if I
develop any adverse reactions or other problems associated with medical marijuana. I understand
that although marijuana has a very long history of thousands of years use as a medicine, its use
as a medicine has not been designated “safe and effective” by the FDA and as such Dr. Blythe
cannot completely vouch for the safety of this plant medicine. I accept all risk of using this
product and agree to indemnify and hold Dr. Blythe harmless regarding any reactions, side
effects, adverse events, or complications related to my use of medical marijuana. I agree that I
will NOT use medical marijuana prior to engaging in any potentially hazardous activities,
including operating a watercraft or motorized vehicle of any type. I agree that any disputes of
any legal nature between myself and Dr. Blythe will be settled by binding arbitration.
I understand that this encounter is an administrative encounter for evaluation to determine
whether or not I qualify for Maine’s legal medical marijuana program (the MMMJ Program) and
for certification or recertification for the use of medical marijuana only. Dr. Blythe will not be
responsible for making a diagnosis or rendering treatment of any sort. This consultation is not
for the purpose of establishing a doctor-patient relationship for the evaluation and/or treatment of
the designated condition or for any other problem. I understand that my primary treating
physician will continue to evaluate and treat all of my medical complaints and conditions. I may
schedule a follow-up appointment with Dr. Blythe or contact him if I have questions about the
effects, benefits, and risks of medical marijuana.
Dr. Blythe does not provide any medical marijuana products or paraphernalia. Maine allows the
options of growing medical marijuana or purchasing it through a licensed dispensary or licensed
grower (called a “caregiver”) . Details of those options are available elsewhere.
Potential side-effects: Marijuana is not known to cause cancer. Smoking any plant material may
aggravate asthma or emphysema, so especially if I have any underlying lung conditions I will use
it in ways other than smoking (eating it, using a tincture, or using a vaporizer). I understand that
exposure to any plant material may trigger allergic reactions such as itching, hives, shortness of
breath, anaphylaxis, and death in sensitive individuals. I understand that marijuana may increase
appetite and lead to weight gain. Chronic overuse of marijuana has been associated with apathy
(lack of caring about anything). There may be some negative impact on reproduction in males
who wish to father children. Marijuana use may cause breast enlargement in men
(gynecomastia). Marijuana is often used to cause euphoria. Often a less than euphoria-inducing
dose is useful for relief of pain, so only that dose needed to provide relief should be used. The
user of medical marijuana must understand that the use of marijuana may make it impossible to
drive or operate dangerous equipment in a safe manner and must avoid dangerous activities
while using it. I understand that I may still be charged with driving under the influence even
with state approval for medicinal use of marijuana.
Legal implications: STATE law makes it legal to use marijuana as medication when approved by
a licensed physician or nurse practitioner. This does not make it legal under federal laws, and it
is still possible to run afoul of federal laws (for example, carrying medical marijuana onto a
military base, into a national park, or on to airport property might expose a user to federal
criminal charges). I will be responsible for becoming familiar with all state laws regarding
medical marijuana and will stay aware of any changes. Using marijuana legally in this state does
not authorize the user to legally transport marijuana into any other state or Canada and does not
allow the user to sell or give marijuana to others. If the court has ordered you not to use drugs
(for example as a condition of parole, child support, or a protection order), you should not
assume that using marijuana medicinally would be legal even if certified and should seek court
approval prior to using it. Likewise, if you are required to submit urine for drug testing as a
requirement for your employment you should inquire about your potential use of medical
marijuana before it becomes an issue. State law offers no protection from job loss for those who
test positive for marijuana and certainly not for those who arrive at work impaired.
I acknowledge that the goal of using medical marijuana is not to get “high” but to treat an
appropriate medical condition. That being said, I understand that marijuana is an intoxicant and I
agree that I will not use it to the point of intoxication if I will be driving or engaging in
hazardous activities. I understand that the combination of sedating or intoxicating chemicals such
as alcohol, narcotics, and sedatives increases the risk of injury or death. Marijuana is a plant – it
is possible to develop allergies or other reactions to it as to any other plant. I agree to stop the
use of medical marijuana if I develop any itching, rash, shortness of breath, or other possible
side effects.
I understand that the use of this herb for medicinal reasons has been approved by the State of
Maine but not by the US Government and many other states. Its use remains illegal in Maine for
those not certified. I agree that I will not seek medical marijuana certification if I am aware that I
may lose my job if I fail a urine drug screen, if I am an employee or consultant of the US
Government who may be required to undergo a urine drug screen, if I possess a DOT
Commercial Driver’s License, or if I possess a federal pilot’s license or captain’s license.
Possession of a Medical Marijuana certification automatically disqualifies a patient from
having a valid DOT physical.
I also agree that I will not use medical marijuana outside of the State of Maine and will never
share or sell my medical marijuana. Any illegal act involving the use of medical marijuana
makes this certificate null and void. I understand that if my certification expires or if I am
notified by Dr. Blythe or the State of Maine that this certification is rescinded I will no longer be
able to legally use marijuana.
I will be truthful with Dr. Blythe in all of my communications and with my paperwork.
Dr. Blythe maintains a “Privacy Policy” which describes how any collected information might be
used. This is generally not relevant since no billing is done. I understand that if I wish to have a
copy of the Privacy Practices I may contact Dr. Blythe or may look online at
www.drblythe.com/marijuana/
I understand that I may have the option to communicate with Dr. Blythe via e-mail. Although
other methods of communication may be more secure in terms of my personal health
information, I consent to communicating with Dr. Blythe via e-mail if I provide an e-mail
address. Dr. Blythe’s e-mail address is: [email protected]
Dr. Stephen Blythe
P.O. Box 411388
Melbourne, FL 32941
Make sure you include your name and contact information.
__________________________________
Signature of Patient
__________________________________
Printed Name
_________________
Date
________________________
E-mail address
Address: ___________________________________________
___________________________________________________
Telephone: _________________________________________
Resources for Medical Marijuana
1. Compassionate Caregivers of Maine 1-866-327-4559 or
www.mainemedmarijuana.com
CCM helps those who grown marijuana for patients, and helps put the two together,
and is a source of information for everyone.
2. Maine Department of Health and Human Services web page for Medical Marijuana – all
the forms, the regulations, and other information you might need:
http://www.maine.gov/dhhs/dlrs/mmm/index.shtml
3. Dr. Blythe’s Website: http://www.drblythe.com/marijuana/ E-mail:
[email protected]
4. Strain information: www.medicalmarijuanastrains.com or www.leafly.com
5. Medical marijuana dispensaries: (addresses are not given – you must call first and you
must have a certificate before you are allowed inside for security reasons)
Maine Organic Therapy
Ellsworth, ME
1-888-360-0650 / 667-0510
www.maineorganictherapy.org
Wellness Connection
Thomaston, ME 04681
1-855-848-6740
www.mainewellness.org
Canuvo, Inc.
Biddeford, ME 04005
602-6130
www.canuvo.org
Wellness Connection
Hallowell, ME 04347
1-855-848-6740
www.mainewellness.org
Safe Alternatives
Eagle Lake, ME 04739
316-9490
http://safealternativesmaine.org
Wellness Connection
Portland, ME 04101
1-855-848-6740
www.mainewellness.org
Remedy Compassion Center
Auburn, ME 04210
800-809-1464
www.remedycompassioncenter.org
Wellness Connection
Brewer, ME 04412
1-855-848-6740
www.mainewellness.org
Medical Marijuana Referral Form for Your Treating Provider
Stephen L. Blythe, D.O.
FAX: 877-220-0488
Your patient, _________________________, has requested a telemedicine consultation to discuss the
use of medical marijuana for a condition for which you are a treating provider. The goal of this
consultation is to discuss pros and cons of medical marijuana and to offer informed consent and medical
marijuana certification if appropriate. In addition, the patient will be provided with a book and an
educational DVD reviewing the laws and responsibilities or medical marijuana, the risks and benefits,
and the methods of using medical marijuana.
A trial of medical marijuana is meant to augment, not interfere with, your current treatment of this
patient. I request that any patient coming for a consultation inform their treating physician of their
intent to be certified and obtain confirmation of their illness and current treatment plan. Patients on
pain management would certainly be expected to have marijuana in any urine drug screens, and their
pain management physician will have to agree not to terminate their ongoing care due to that finding.
All patients are advised that possession of a medical marijuana certificate is an automatic disqualifier for
interstate commercial driving in that it voids the DOT health certificate. They of course are also strongly
cautioned never to allow themselves to engage in any dangerous activity if they are impaired.
I do not provide medical marijuana certification to any patient who has a history of multiple drug abuse,
a history of drug arrests, or who has a commercial driver’s license, pilot’s license, or captain’s license.
Please do not complete this form if you know of any reason this patient should not use medical
marijuana.
I would appreciate your confirming that you are treating this patient for the following problem(s):
Multiple Sclerosis, ALS, or other neurodegenerative disease
HIV/AIDS
Hepatitis C
Fibromyalgia with chronic pain
Glaucoma
Chronic back pain or other chronic musculoskeletal pain
Neuropathic pain
Crohn’s Disease or Ulcerative Colitis
Alzheimer’s Disease with agitation
Cancer or cancer treatment causing nausea, pain, or weight lost/wasting
Post-traumatic stress disorder (PTSD)
Other intractable pain, muscle spasm, nausea, or wasting syndrome
Please fax me copies of the problem list, medication list, and the past two or three office visits to
document their eligibility for medical marijuana under Maine laws.
Mental health providers: please just fax the attached form stating that you are treating the patient for
one of the above qualifying conditions (and check above).
[PAGE ONE OF TWO]
Please be aware that ONLY those conditions above are qualifying conditions for medical marijuana in
Maine. Anxiety, depression, insomnia, and bipolar disorder are NOT qualifying conditions at this time.
I will not assume any other aspect of treatment of this patient’s condition.
Sincerely,
Stephen Blythe, D.O.
Patient Consent:
I, _____________________________, give ___________________________
permission to communicate with Dr. Stephen Blythe regarding my care. This consent applies to any
information needed to complete this form as above and to provide the requested copies. I also give Dr.
Blythe permission to discuss my care with my treating provider/physician if necessary.
This consent is valid for eighteen months unless revoked in writing. I understand that if this consent is
revoked in writing my medical marijuana certificate becomes void and will no longer be supported or
substantiated by Dr. Blythe.
Signed: _____________________________________ Date: __________________
Printed Name: _______________________________
Provider Acknowledgement:
I am treating _________________________________________ for the above-indicated condition. I
understand that they will be seeing Dr. Blythe for a medical marijuana consultation and possible
certification. I will not terminate their treatment for this reason.
Signed: _____________________________________________ Date: ___________________
Clinic or Affiliation:__________________________________ Phone: ___________________
Printed Name: _____________________________________
Please fax both pages of this form with your official fax cover sheet to the
following private fax number: FAX: 877-220-0488
Please Do Not Mail this form or records. Make sure the patient does not leave
their other forms with your office. Thank you for your cooperation and
assistance