Louisiana Administrative Code
Title 46 - PROFESSIONAL AND OCCUPATIONAL STANDARDS
Part XLV - Medical Professions
Subpart 3 - Practice
Chapter 77 - Marijuana for Therapeutic Use by Patients Suffering from a Debilitating Condition
Subchapter E - Sanctions, Severability
Section XLV-7729 - Appendix-Form for Recommendation for Therapeutic Marijuana
-THIS IS NOT A PRESCRIPTION-
PHYSICIAN RECOMMENDATION FORM
Section A. Patients Physician Information (Required)
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1. Legal First Name |
2. Middle Initial |
3a. Legal Last Name |
3b. Suffix (Jr., Sr., Ill, etc.) |
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4a. Full Professional Address (street, city (in LA), zip code) 4b. e-mail address 4c.fax number |
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5. City |
6. State |
7. Zip Code |
8. Telephone Number |
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9a. LSBME Registration No. for Therapeutic Marijuana No. _______________ |
9b. Schedule I No. (Board of Pharmacy) for Therapeutic Marijuana No. _______________ |
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Section B. Patient Information (Required)
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10. Legal First Name |
11. Middle Initial |
12a. Legal Last Name |
12b. Suffix (Jr., Sr., Ill, etc.) |
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13. Date of Birth |
4. Full Address of Patient [street, city (in LA), zip code] |
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Section C. Patients Debilitating Medical Condition(s) (Required)
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This patient has been diagnosed with the following debilitating medical condition: (A minimum of one condition must be checked) |
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___ Acquired Immune Deficiency Syndrome |
___ Intractable Pain |
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___ Post-Traumatic Stress Disorder |
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___ Cachexia or Wasting Syndrome |
___ Any of the following conditions associated with autism spectrum disorder: |
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___ Cancer |
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___ Crohns Disease |
___ (i) repetitive or self-stimulatory behavior of such severity that the health of the person with autism is jeopardized; |
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___ Epilepsy |
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___ Multiple Sclerosis |
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___ Muscular Dystrophy |
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___ Positive Status for Human Immunodeficiency Virus |
___ (ii) avoidance of others or inability to communicate of such severity that the physical health of the person with autism is jeopardized; |
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___ Spasticity |
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___ Seizure Disorders |
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___ Glaucoma |
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___ Parkinsons Disease |
___ (iii) self-injuring behavior; |
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___ Severe Muscle Spasms |
___ (iv) physically aggressive or destructive behavior. |
Section D. Form, A mount, Dose, and Instructions for Use of Therapeutic Marijuana (Required)
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_________________________________________________________________________________ |
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_________________________________________________________________________________ |
Section E. Certification, Signature and Date (Required)
By signing below, I attest that the information entered on this recommendation is true and accurate. I further attest that the above-named individual is my patient, who suffers from a debilitating medical condition and that this recommendation is submitted by and in conformity with Louisiana Law, R.S. 40:1046, and administrative rules promulgated by the Louisiana State Board of Medical Examiners, LAC 46:XLV.Chapter 77.
Signature of Physician: X____________________________
Date: _____________________
AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1261-1292, and R.S. 40:1046.
