These forms should be filled out after you have booked and paid for your appointment at assuredclinic.com. Please complete all applicable forms at least 24 hours before your scheduled telehealth visit. Your provider will review them prior to your appointment.
Complete this registration form for your first visit. All fields marked * are required.
I the undersigned:
Acknowledge that it is my responsibility to pay for all charges associated with my care at Assured Health.
Acknowledge the receipt of the Notice of Privacy Practices. If you have any questions concerning your rights and/or our privacy practices, please contact Assured Health.
Authorize Assured Health to release information from the patient's health records for purposes of processing and paying claims, coordinating benefits, coordinating care, quality care review studies, and other functions that support treatment, payment and healthcare operations.
Authorize the patient's health plan to release health information to appropriate accreditation and quality review/measurement personnel, to disease, pharmacy, or case management providers and to other third parties for purposes related to treatment, payment, or healthcare operations.
• The right to reasonable requests to receive confidential communication of my PHI
• The right to inspect and copy my PHI
• The right to receive an accounting of disclosures of my PHI
• The right to request an amendment of my PHI
Acknowledge that I understand that I may revoke (cancel) this consent, in writing, at any time. Revoking consent does not apply to information that has already been disclosed.
By typing your full name below, you are providing your electronic signature confirming all information is accurate and that you agree to the terms above.
Check all symptoms or conditions that currently apply to you. This helps your provider prepare for your visit.
Please provide your medical history, surgeries, hospitalizations, and current medications.
List your diagnosed medical conditions and approximate date of onset (mm/yy).
Include name, dosage, and frequency for all medications including over-the-counter and supplements.
This form is required by the Minnesota Department of Health to register your email address with the Medical Cannabis Patient Registry. Bring a copy to your appointment.
The information requested by the Medical Cannabis Patient Registry will be used to communicate with you, establish your eligibility and identity, and for MDH to evaluate information on patient demographics, effective treatment options, clinical outcomes, and quality-of-life outcomes for the purpose of reporting on the benefits, risks and outcomes regarding patients with a qualifying medical condition engaged in the therapeutic use of medical cannabis.
The information contained in the Patient Registry is considered private data on individuals. Your email address will serve as your user name during account registration. User name, password, and security question answers are also private data.
You are not legally required to provide any of the requested information. However, failure to provide required information could result in the delay or denial of your enrollment application.
Pharmacy staff at state-registered medical cannabis manufacturers, your certifying health care practitioner, your designated caregiver (if applicable), and law enforcement officials with a valid search warrant may access your registry information.
By creating a Medical Cannabis Patient Registry account, you are indicating that you have read and understand this notice and the intended use of the data and information you provide.
By typing your full name below, you are providing your electronic signature for this acknowledgement form.
Please read this agreement carefully before signing. It governs the terms of your medical cannabis certification service with Assured Health LLC.
Assured Health LLC will provide: comprehensive medical evaluation, review of medical history and medications, discussion of benefits/risks of medical cannabis, certification if eligible, and guidance on enrollment in the Minnesota Medical Cannabis Program.
• I will provide complete, truthful, and accurate information regarding my medical history.
• I am at least 18 years of age or have a registered caregiver/parent.
• I am a Minnesota resident with valid proof of residency.
• I will comply with all federal, state, and local laws regarding medical cannabis.
• I will not share, sell, or distribute medical cannabis to any other person.
• I understand that medical cannabis is not FDA-approved and evidence varies by condition.
• Certification does not guarantee therapeutic benefit.
Evaluation Fee: Initial Certification — $175.00 | Recertification — $150.00 (payable at time of service).
The evaluation fee is non-refundable regardless of outcome. Payment is for professional services rendered, not a guarantee of certification. Annual re-certification evaluations are required and subject to applicable fees. Medical cannabis certification services are typically not covered by insurance. Separate fees payable to the Minnesota OCM are the responsibility of the patient.
Potential side effects include: dizziness, drowsiness, impaired coordination, increased heart rate, anxiety, and potential for psychological dependence with prolonged use.
Guidelines: Do NOT use with alcohol or mind-altering substances. Do NOT drive or operate machinery while using. Use the smallest effective amount. Respect the rights of others and all applicable laws. If pregnant, STOP use and consult your OB/GYN.
Cannabis remains a Schedule I controlled substance under federal law. Participation in any state medical cannabis program does not provide immunity from federal prosecution.
Patient records are protected health information under HIPAA. Provider will not disclose Patient's information without written consent, except as required by law.
Provider's role is limited to evaluation and certification. Provider makes no guarantees regarding therapeutic outcomes. This Agreement does not establish a primary care relationship beyond cannabis certification services.
This Agreement is governed by the laws of the State of Minnesota. Venue for any legal proceedings shall be Hennepin County, Minnesota.
By typing your full name below, you are providing your electronic signature confirming agreement to all terms above.
For returning patients only. This survey helps us evaluate how medicinal cannabis is working for your qualifying condition.
On a scale of 0–7 (0 = No benefit, 7 = A great deal of benefit), how has Medicinal Cannabis improved your qualifying condition(s)?
Have you experienced any negative effects from Medicinal Cannabis? (check all that apply)
Have you stopped using Medicinal Cannabis only to experience worsening symptoms of your qualifying condition(s)?
How does (or did) Medicinal Cannabis affect your conditions or symptoms overall? (select one)
Did you decrease or discontinue your use of other medicines when you started using Medicinal Cannabis for your condition(s)?
Have you told any health service providers about your Medicinal Cannabis use?
If yes, which providers and were they supportive?