1. (a) The certifying provider shall complete a “Written Certification for the Therapeutic Use of Cannabis” form, which includes the following:

   1. (1) Indication whether it is an initial or renewal certification;

   2. (2) The following patient information:

      1. a. Full name;
      2. b. Mailing address;
      3. c. Date of birth; and
      4. d. Telephone number; and

   3. (3) The following provider information:

      1. a. Full name;
      2. b. Name of medical practice;
      3. c. Office mailing address;
      4. d. Office telephone and fax numbers;
      5. e. Email address;
      6. f. State license number;
      7. g. Indication that the provider is a physician (MD or DO), a physician associate or assistant (PA), an advanced practice registered nurse (APRN), or another provider type authorized by RSA 126-X:1, VII(a)(5);
      8. h. Active US Drug Enforcement Administration registration number; and
      9. i. Medical specialty, as appropriate for the provider type.

2. (b) On the “Written Certification for the Therapeutic Use of Cannabis” form, the provider shall:

   1. (1) Certify that the patient has a qualifying medical condition, as defined in He-C 401.02(j) and RSA 126-X:1, IX(a) or (b), by:

      1. a. Providing the patient’s name;
      2. b. Indicating which condition(s) the patient has;
      3. c. For a diagnosis of opioid use disorder with associated symptoms of cravings or withdrawal, or both, providing the provider’s addiction medicine or addiction psychiatry certification board name and certification number;
      4. d. For patients 21 years old or older, if applicable, indicating the specific debilitating or terminal medical condition or symptom the patient has, which is not listed in RSA 126-X:1, IX(a) or (b)(1)-(7), and certifying that the potential benefits of using therapeutic cannabis would, in the provider’s clinical opinion, likely outweigh the potential health risks for the patient; and
      5. e. Signing and dating the certification;
   2. (2) Indicate whether the written certification is based on an in-person physical examination or an examination that was conducted via telemedicine;
   3. (3) For a diagnosis of autism spectrum disorder for patients under age 21, certify that the provider has consulted with a certified provider of child or adolescent psychiatry, or both, developmental pediatrics, or pediatric neurology, who has confirmed that the autism spectrum disorder has not responded to previously prescribed medication or for which other treatment options produced serious side effects, and who supports certification for the therapeutic use of cannabis;

   4. (4) Certify that the provider has a provider-patient relationship with the patient, as follows:

      “I have completed a full assessment of my patient’s medical history and current medical condition in accordance with He-C 401.06(b)(4) made in the course of a provider-patient relationship”;

   5. (5) Certify that the provider explained the potential health effects of the therapeutic use of cannabis:

      1. a. To the patient; or
      2. b. In the case of a patient who is a minor, to the patient’s custodial parent or legal guardian with responsibility for health care decisions for the patient, which shall be inclusive of the potential risks and benefits of the therapeutic use of cannabis;

   6. (6) Certify that the provider counseled:

      1. a. The patient, if the patient is a woman of child-bearing age, and the patient’s custodial parent or legal guardian if the patient is a minor, about the risks of cannabis use during pregnancy and while breastfeeding; and
      2. b. The patient, if the patient is an adolescent 25 years of age or less, and the patient’s custodial parent or legal guardian if the patient is a minor, about the risks of cannabis use in adolescence;

   7. (7) Certify that the provider possesses an active license in good standing with the state of New Hampshire or the state of Maine, Massachusetts, or Vermont and is either:

      1. a. A physician, an advanced practice registered nurse, or a physician associate licensed in New Hampshire to prescribe drugs to humans under RSA 329, RSA 326-B:18, or RSA 328-D, respectively, and who possesses an active registration from the United States Drug Enforcement Administration to prescribe controlled substances;
      2. b. Another provider type licensed in New Hampshire to prescribe drugs to humans under the relevant New Hampshire licensing laws, who possesses an active registration from the United States Drug Enforcement Administration to prescribe controlled substances, and who is primarily responsible for the patient’s care related to the patient’s qualifying medical condition; or
      3. c. A physician, physician associate, or an advanced practice registered nurse licensed in Maine, Massachusetts, or Vermont to prescribe drugs to humans under the relevant state licensing laws, who possesses an active registration from the United States Drug Enforcement Administration to prescribe controlled substances, and who is primarily responsible for the patient’s care related to the patient’s qualifying medical condition;
   8. (8) Certify that the facts as stated in the written certification are accurate to the best of the provider’s knowledge and belief and that the provider understands that any false statements made on the written certification are punishable as unsworn falsification under RSA 641:3; and
   9. (9) Indicate the duration for which the registry identification card shall be valid, up to a maximum of 3 years, except that if this is not indicated, the card shall default to a duration of one year.

Source. (See Revision Note #1 at part heading for He-C 401) #10646, eff 11-2-15; ss by #13220, eff 7-1-21 (see Revision Note #2 at part heading for He-C 401); ss by #13567, eff 5-1-23; ss by #14386, eff 10-1-25, EXPIRES: 10-1-35