California Medical (Cannabis) Marijuana HIPPA Waiver Health Information and Privacy Disclosure 

I am aware of my right to privacy of my health related information. I assert all privacy rights as allowed for all legal medications including Cannabis in all its forms. I retain all such privacy as HIPPA and Proposition 215, as well as Senate Bill 420 protect and authorize, as a legal medical cannabis patient.

I hereby authorize the use and disclosure of the medical information contained in the medical recommendation of my physician for medical (cannabis) marijuana and confirmation with the doctor by the collective, from time to time. 

I also understand a copy of my record will be kept by the collective on file.

I understand that the collective's policy on privacy is to not disclose the name or identity of any patient other than in the course of confirmation of the recommendation. I understand that I may have extra protection under California and Federal law as to my information. However, I expressly authorize the use and storage of this information in accordance herewith. 

I understand I may revoke my authorization in writing at any time and that the collective will then maintain a record, but block out my name. I understand I am under no obligation to sign this form; however I realize that in order to ask the collective to provide me access to medical (cannabis) marijuana and at my own personal request for instance, I grant the right to the information as described herein.

I understand I have a right to inspect or copy this authorization, and my file with the collective. I understand that there is the possibility of inadvertent disclosure of information in the course of confirming my recommendation. 

This authorization shall terminate on the termination of my medical (cannabis) marijuana recommendation unless terminated sooner in writing by me. I have had an opportunity to review this form, and I confirm it accurately reflects my wishes.

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Signed Date

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Print Name

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Signature of Parent or Guardian if patient is a minor or unable to sign