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

Current through Register Vol. 50, No. 6, June 20, 2024
-THIS IS NOT A PRESCRIPTION-
PHYSICIAN RECOMMENDATION FORM
Section A. Patients Physician Information
						(Required)
1. Legal First Name
2. Middle Initial
3a. Legal Last Name
3b. Suffix (Jr., Sr., Ill, etc.)
4a. Full Professional Address (street, city (in
								  LA), zip code) 4b. e-mail address 4c.fax number
5. City
6. State
7. Zip Code
8. Telephone Number
9a. LSBME Registration No. for Therapeutic
								  Marijuana
No.
_______________
9b. Schedule I No. (Board of Pharmacy) for
								  Therapeutic Marijuana
No.
_______________
Section B. Patient Information
						(Required)
10. Legal First Name
11. Middle Initial
12a. Legal Last Name
12b. Suffix (Jr., Sr., Ill, etc.)
13. Date of Birth
4. Full Address of Patient [street, city (in LA),
								  zip code]
Section C. Patients Debilitating Medical
						Condition(s) (Required)
This patient has been diagnosed with the
								  following debilitating medical condition:
(A minimum of one condition must be
								  checked)
___ Acquired Immune Deficiency Syndrome
___ Intractable Pain
___ Post-Traumatic Stress Disorder
___ Cachexia or Wasting Syndrome
___ Any of the following conditions associated
								  with autism spectrum disorder:
___ Cancer
___ Crohns Disease
___ (i) repetitive or self-stimulatory behavior
								  of such severity that the health of the person with autism is
								  jeopardized;
___ Epilepsy
___ Multiple Sclerosis
___ Muscular Dystrophy
___ 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;
___ Spasticity
___ Seizure Disorders
___ Glaucoma
___ Parkinsons Disease
___ (iii) self-injuring behavior;
___ Severe Muscle Spasms
___ (iv) physically aggressive or destructive
								  behavior.
Section D. Form, A mount, Dose, and Instructions
						for Use of Therapeutic Marijuana (Required)
_________________________________________________________________________________
_________________________________________________________________________________
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.