Qualify + Register

HOW TO QUALIFY

Cancer, glaucoma, positive status for human immunodeficiency virus, acquired immune deficiency syndrome, hepatitis C, amyotrophic lateral sclerosis, muscular dystrophy, Crohn’s disease, multiple sclerosis, chronic pancreatitis, spinal cord injury or disease, traumatic brain injury, epilepsy, lupus, Parkinson’s disease, Alzheimer’s disease, ulcerative colitis, Ehlers-Danlos syndrome, or one or more injuries or conditions that has resulted in one or more qualifying symptoms below

AND

A severely debilitating or terminal medical condition or its treatment that has produced at least one of the following: elevated intraocular pressure, cachexia, chemotherapy-induced anorexia, wasting syndrome, agitation of Alzheimer’s disease, severe pain that has not responded to previously prescribed medication or surgical measures or for which other treatment options produced serious side effects, constant or severe nausea, moderate to severe vomiting, seizures, or severe, persistent muscle spasms

OR

“Qualifying medical condition” also means:

  • Moderate to severe chronic pain.
  • Severe pain that has not responded to previously prescribed medication or surgical measures or for which other treatment options produced serious side effects.
  • Moderate or severe post-traumatic stress disorder.
CONDITIONSSYMPTOMS
Acquired Immune Deficiency SyndromeCachexia
Alzheimer’s DiseaseChemotherapy-induced anorexia
ALSConstant or severe nausea
CancerModerate to severe vomiting
Chronic PancreatitisElevated intraocular pressure
Crohn’s DiseaseSeizures
Ehlers-Danlos SyndromeWasting syndrome
EpilepsySevere, persistent muscle spasms
GlaucomaSevere pain for which other treatment options produced serious side effects.
Hepatitis C, must be currently receiving anti-viral treatmentsSevere pain not responding to previously prescribed medications or surgical procedures
HIVAgitation of Alzheimer's Disease
Lupus
Moderate or Severe Post-Traumatic Stress Disorder
Moderate to Severe Chronic Pain
Multiple Sclerosis
Muscular Dystrophy
Parkinson’s Disease
Spinal Cord Injury/Disease
Traumatic Brain Injury
Ulcerative Colitis
Severe pain that has not responded to previously prescribed medication or surgical measures or for which other treatment options produced serious side effect
One or more injuries or conditions that has resulted in one or more qualifying symptoms [listed in the law]

HOW TO REGISTER

STEP 1: If you believe you may be a good candidate for the program, download the Provider Form (here) to bring to your physician.

STEP 2: Download and complete the Patient Application (here).

STEP 3: Submit both forms, proof of NH residency, a digital photograph of your face (for use in registry card), and mail $50 application fee payable by check to “Treasurer, State of New Hampshire”, and mail to:

NH Department of Health & Human Services
Therapeutic Cannabis Program – Brown Building
129 Pleasant Street
Concord, NH 03301

For technical assistance, please refer to the Qualifying Patients Instructions on the DHHS website (here), for further guidance.

HAVE QUESTIONS?

GET IN TOUCH

(888) 298-7746

info@primeatc.com

www.primeatc.com

Opening Spring 2016

380 Daniel Webster Highway, Merrimack, NH 03054