Petition for Addition of Qualifying Conditions

Petition for Addition of Qualifying Conditions

Medical Cannabis Program

Mississippi State Department of Health

Petitioner Information

Name*

Interest in MS Medical Cannabis Program*

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Email Address*

Phone Number*

Phone

Address of Physical Residence

City*

State*

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Preferred Method of Contact*

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Proposed Disease, Disorder, or Condition Details

For the purposes of this petition, "disease, disorder, or condition" refers to a state of health that generally requires treatment or intervention following its diagnosis by licensed medical professional acting within their respective scope of practice and is chronic and/or debilitating in nature.

Formal Name of Condition*

Petitions lacking clinically appropriate nomenclature will not be considered

ICD-11 Code*

Hierarchal level will be considered

ICD-11 Description*

Supporting Documentation*

Must attach a minimum of 3 scholarly articles or research papers justifying indication of medical cannabis use for the proposed condition. Peer-reviewed sources preferred. Items from inappropriate sources will not be considered.

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