Email Address

Direct Email Address (The email address entered here should be your direct email address that no one else besides you has access to. Do not enter an email address that is shared with other providers or office staff)

Middle Initial

Create a 4-digit PIN. Do not use sequential or repeating numbers such as "1234" or "2222". Your PIN is required each time you issue a Provider Certification.

Health Care Provider PIN

Health Care Provider - Proof of Identity

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Please provide your valid and current Colorado Driver's License or Colorado ID Card information:

Colorado Driver License/ Colorado ID Card Number Colorado Driver License/ Colorado ID Card Issue Date Colorado Driver License/ Colorado ID Expiration Date Upload a pdf or jpeg file copy of your valid and current Colorado Driver's License or Colorado ID Card Date of Birth Current Home Address Current Home Apt/Suite # Current Home City Current Home County

Current Home State

CO

Current Home Zip

Health Care Provider - Credentials

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National Provider Identification Number Colorado Health Care Provider License Type

Colorado Health Care Provider License Status

The license status you selected requires additional information.
Please upload a copy of your mentoring agreement
between you and your mentor Colorado Health Care Provider License Number (Exclude all letters and leading zeroes) Colorado Health Care Provider License Expiration Date Upload a copy of your Colorado Health Care Provider License issued by DORA Upload a copy of your registered nurse license issued by your home state DEA Certification Number DEA Certification Expiration Date Upload a copy of your DEA Certification. Your DEA certification must have been issued with your Colorado address

Health Care Provider - Business Contact Information

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Business Address Business Apt/Suite # Business City Business County

Business State

CO

Business Zip General Office Phone Number (The phone number entered here should be main number to your practice) Direct Phone (The phone number entered here should be your direct line or cell number. Do not enter a phone number to your main practice where someone other than you will answer the line) General Office Email (The email address entered here should be an email that is shared with other provider or office staff to receive information)

Health Care Provider - Confidentiality Agreement

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I hereby certify that I have verified the above information to be accurate and complete and no one other than me is submitting this request.
I authorize the Medical Marijuana Registry to contact me using the telephone number and email address I provided. I understand incomplete applications will not be accepted.
By registering with this system you are agreeing to follow the stated Confidentiality Agreement.

Electronic Signature