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Green Cross Partners

Serving Michigan Since 2009!

616-755-8966

3737 Lake Eastbrook Blvd. SE, Ste. 103, Grand Rapids, MI 49546

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$170 Full Service: Telehealth: Pre-Qualification

Please fill out the following form to help us understand your physical condition.

First Name

Last Name

Phone

Date of Birth:

Email Address

Address to Mail MMP Card:

Michigan ID/License #: (Include first letter.)

ID/License Expiration Date:

Wht is/are your state qualifying condition(s)?

Cancer

Chronic Pain

Arthritis

Rheumatoid Arthritis

Severe Nausea

(PTSD) Post Traumatic Stress Disorder

(OCD) Obsessive Compulsive Disorder

Autism

Glaucoma

HIV Positive

AIDS

Hepatitis C

Amyotrophic Lateral Sclerosis

Cachexia or Wasting Syndrome

Severe Chronic Pain

Seizures (Including but not limited to those characteristics of epilepsy.)

Spinal Cord Injury

Colitis

Inflammatory Bowel Disease

Ulcerative Colitis

Parkinson's Disease

Tourette's Syndrome

Cerebral Palsy

Note to Doctor: Briefly describe (1) of your state qualifying condition(s)

Do you have medical records? If yes, where are they filed?

Current Rx Medications

Have you ever had a MMMP card at any time?

Yes

Is this appointment to get a MMMP card for the FIRST TIME or to RENEW an existing card?

If you selected YES and your card is NOT EXPIRED, please provide PIN #:

I declare that the info I’ve provided is accurate & complete

I agree to the terms & conditions

Thanks for scheduling!