Medican Marijuana Request Form

New Jersey Department of Health
Medicinal Marijuana Program

PO 360
Trenton, NJ 08625-0360
MEDICINAL MARIJUANA PETITION

(N.J.A.C. 8:64-5.1 et seq.)
INSTRUCTIONS
This petition form is to be used only for requesting approval of an additional medical condition or treatment thereof as a
debilitating medical condition pursuant to the New Jersey Compassionate Use Medical Marijuana Act, N.J.S.A. 24:6I-3. Only
one condition or treatment may be identified per petition form. For additional conditions or treatments, a separate petition form
must be submitted.
NOTE: This Petition form tracks the requirements of N.J.A.C. 8:64-5.3. Note that if a petition does not contain all
information required by N.J.A.C. 8:64-5.3, the Department will deny the petition and return it to petitioner without
further review. For that reason the Department strongly encourages use of the Petition form.
This completed petition must be postmarked August 1 through August 31, 2016 and sent by certified mail to:
New Jersey Department of Health
Office of Commissioner - Medicinal Marijuana Program
Attention: Michele Stark
369 South Warren Street
Trenton, NJ 08608
Please complete each section of this petition. If there are any supportive documents attached to this petition, you should
reference those documents in the text of the petition. If you need additional space for any item, please use a separate piece
of paper, number the item accordingly, and attach it to the petition.
1.
Petitioner Information
Name:
Street Address:
City, State, Zip Code:
Telephone Number:
Email Address:
2.
Identify the medical condition or treatment thereof proposed. Please be specific. Do not submit broad categories (such
as mental illness).
3.
Do you wish to address the Medical Marijuana Review Panel regarding your petition?
Yes, in Person
Yes, by Telephone
No
4.
Do you request that your personally identifiable information or health information remain confidential?
Yes
No
If you answer Yes to Question 4, your name, address, phone number, and email, as well as any medical or health information
specific to you, will be redacted from the petition before forwarding to the panel for review.
OC-8
JUL 16
Page 1 of 3 Pages.

(Continued)
5.
Describe the extent to which the condition is generally accepted by the medical community and other experts as a valid,
existing medical condition.
6.
If one or more treatments of the condition, rather than the condition itself, are alleged to be the cause of the patient's
suffering, describe the extent to which the treatments causing suffering are generally accepted by the medical
community and other experts as valid treatments for the condition.
7.
Describe the extent to which the condition itself and/or the treatments thereof cause severe suffering, such as severe
and/or chronic pain, severe nausea and/or vomiting or otherwise severely impair the patient's ability to carry on
activities of daily living.
8.
Describe the availability of conventional medical therapies other than those that cause suffering to alleviate suffering
caused by the condition and/or the treatment thereof.
9.
Describe the extent to which evidence that is generally accepted among the medical community and other experts
supports a finding that the use of marijuana alleviates suffering caused by the condition and/or the treatment thereof.
[Note: You may attach articles published in peer-reviewed scientific journals reporting the results of research on the effects of
marijuana on the medical condition or treatment of the condition and supporting why the medical condition should be added to
the list of debilitating medical conditions.]
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JUL 16
Page 2 of 3 Pages.

(Continued)
10. Attach letters of support from physicians or other licensed health care professionals knowledgeable about the
condition. List below the number of letters attached and identify the authors.
I certify, under penalty of perjury, that I am 18 years of age or older; that the information provided in this petition is
true and accurate to the best of my knowledge; and that the attached documents are authentic.
Signature of Petitioner
Date
OC-8
JUL 16
Page 3 of 3 Pages.

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New Jersey Department of Health

Medicinal Marijuana Program

MEDICINAL MARIJUANA PETITION

City, State, Zip Code:

MEDICINAL MARIJUANA PETITION

MEDICINAL MARIJUANA PETITION

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