Designation of Caregiver/Patient Authorization Form

This form is to be utilized by the patient enrollment in the Mississippi Cannabis Program to indicate his/her intent to designate an individual to act as his/her caregiver. A designated caregiver must be at least twenty-one (21) years of age and has agreed to assist a registered qualifying medical cannabis patient with their use of medical cannabis.

Include the person's first and last name.

This must match the patient name approved by the Medical Cannabis Program.

This is the patient number assigned by the Medical Cannabis Program.

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