Application | Utah Patients Coalition

First Name *

Middle Name

Last Name *

I have a valid Utah Medical Cannabis Card *YesNo

Patient ID Number *

Preferred Pharmacy *

Email Address *

Phone *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Please Check all that apply:

I am a VeteranI am a Senior CitizenI am Physically DisabledI am Currently Receiving DisabilityI am Currently Receiving Social SecurityI am Currently Receiving Government Financial AssistanceI am Considered Terminal by a Medical Provider

Please explain why you would like to be considered for the Utah Patient Subsidy Program? *

For how long are you seeking assistance? *TemporaryOngoing

Do you have a Medical Cannabis qualifying condition? *YesNo

Qualifying medical condition:

What conditions or symptoms do you use cannabis for? *Please list all conditions whether they are qualifying conditions or not.

Are you currently receiving hospice care? *YesNo

Are you currently employed? *YesNo

Do you have health insurance? *YesNo

Do you have children under the age of 18 living in your home? *YesNo

Where do you currently get your cannabis from?

Would you be able to contribute any amount of money towards your medication? *YesNo

How much would you be able to contribute? *

USD

Do you have a caregiver? *YesNo

Do you need a caregiver? *YesNo

Do you feel you are getting the maximum therapeutic benefits from medical cannabis? *YesNo

Would you want to speak with a QMP/Pharmacist to assist you to maximize the therapeutic benefits of Cannabis?YesNo

Please list any other information that you would like us to know or feel is important for us to know about your conditions, financial situation, etc.. *

Upload any financial or medical information that you feel would be beneficial to us.

(Optional)

HIPPA Information Release *

By signing this document I declare that the information I have provided in this application and in all of the included supporting documents is accurate, true to the best of my knowledge and is provided of my own free will. I have read and I understand the program requirements as described in the application instructions. I understand that completion of this application does not guarantee that I will receive services.

I understand that the Utah Patients Subsidy Program services are provided at Utah Patients Coalition discretion and that UPC may modify the program at any time. The information provided on this form will be kept confidential and will be used strictly to determine eligibility for the UPSP program. No identifying information will be released without written permission from the Applicant.

Utah Patients
Subsidy Application

Please Check all that apply:

What form of cannabis do you currently medicate with? *

What form of cannabis is MOST EFFECTIVE for your condition? *

Utah PatientsSubsidy Application

Please Check all that apply:

What form of cannabis do you currently medicate with? *

What form of cannabis is MOST EFFECTIVE for your condition? *

Utah Patients
Subsidy Application