1. (a) The minor applicant’s custodial parent(s) or legal guardian who is responsible for the health care decisions of the minor applicant shall complete and submit the “Minor Patient Application” form described in (c) below.
2. (b) The “Minor Patient Application” form shall be a combined application for both the minor applicant and the designated caregiver applicant(s).

3. (c) The minor applicant’s custodial parent(s) or legal guardian shall include the following on the “Minor Patient Application”:

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

   2. (2) The following minor applicant information:

      1. a. Full name;
      2. b. Date of birth;
      3. c. Gender;
      4. d. Mailing address; and
      5. e. Physical address, if different than mailing address, except that if the minor applicant is experiencing homelessness this shall not be required;

   3. (3) The following information about the designated caregiver applicant(s):

      1. a. Full name;
      2. b. Date of birth;
      3. c. Gender;
      4. d. Phone number;
      5. e. Mailing address, if different than the minor applicant; and
      6. f. Physical address, if different than the minor applicant;

   4. (4) The following information about the minor applicant’s certifying providers:

      1. a. First and last name;
      2. b. Business address; and
      3. c. Telephone number;
   5. (5) A signed and dated release authorizing the release of relevant medical information by the certifying providers to the department if further information about the minor applicant’s qualifying medical condition or written certification is required by the department;

   6. (6) Signed and dated attestation(s) of the following minor patient requirements:

      1. a. “I am the custodial parent or legal guardian responsible for the health care decisions of the applicant.”;
      2. b. “The applicant’s certifying providers have explained to me the potential risks and benefits of the therapeutic use of cannabis.”;
      3. c. “I consent to allow the applicant’s therapeutic use of cannabis.”;
      4. d. “I consent to serve as the applicant’s Designated Caregiver and to control the acquisition of cannabis and the frequency of the therapeutic use of cannabis by the applicant.”;
      5. e. “I understand that if I am not approved to be a Designated Caregiver, then the applicant’s application to be a Qualifying Patient shall not be approved.”; and
      6. f. If applicable, “I share legal custody of the applicant, and I have notified the other parent or guardian with legal custody of the applicant in advance of submitting this application by having provided to the other parent or guardian a copy of the completed Application form and the completed Written Certification forms.”;

   7. (7) Signed and dated attestation(s) of the following acknowledgements:

      1. a. “I understand that Registry ID Cards are valid for one year, unless a shorter or longer duration is indicated by the patient’s medical provider. Cards must be renewed or extended prior to their expiration in order to prevent a lapse in registration.”;
      2. b. “I understand that if I am notified of a denial or a revocation I have 30 days from the date of the notice to appeal the decision, and that if a request for an appeal is not made within that timeframe then I will have waived my right to an appeal and the action of the Department shall become final.”;
      3. c. “I understand that I may not possess, between myself and my Qualifying Patient(s), more than 2 ounces of cannabis per Qualifying Patient, or obtain more than 2 ounces of cannabis in any 10-day period from any source per Qualifying Patient.”;
      4. d. “I understand that as a Designated Caregiver I am not permitted to use cannabis, unless I am also a Qualifying Patient, and may be subject to criminal penalties if I do so.”;
      5. e. “I understand that my Qualifying Patient may only use cannabis for the purpose of treating or alleviating their qualifying medical condition.”;
      6. f. “I understand that as a Designated Caregiver I am not permitted to possess any cannabis for purposes other than its therapeutic use as permitted by RSA 126-X.”;
      7. g. “I understand that my Qualifying Patient may not be under the influence of cannabis: (1) while operating a motor vehicle, commercial vehicle, boat, vessel, or any other vehicle propelled or drawn by power other than muscular power; (2) in their place of employment, without the written permission of the employer; or (3) while operating heavy machinery or handling a dangerous instrumentality.”;
      8. h. “I understand that my Qualifying Patient may not smoke or vaporize cannabis in any public place, including a public bus or other public vehicle, or any public park, public beach, or public field.”;
      9. i. “I understand that my Qualifying Patient and I may not be in possession of cannabis in any of the following locations: (1) the building and grounds of any preschool, elementary, or secondary school, which are located in an area designated as a drug free zone; (2) a place of employment, without the written permission of the employer; (3) any correctional facility; (4) any public recreation center or youth center; or (5) any law enforcement facility.”;
      10. j. “I understand that my Qualifying Patient may use cannabis on privately-owned real property only with written permission of the property owner or, in the case of leased property, with the permission of the tenant in possession of the property.”;
      11. k. “I understand that in the event of my Qualifying Patient’s death, I will, within 5 days of the death: (1) notify the Program of the death; and (2) either request that the local law enforcement agency remove any remaining cannabis or dispose of the remaining cannabis in a manner that is specified in RSA 126-X:2, XIV.”;
      12. l. “I understand that if my Qualifying Patient or I am found to be in possession of cannabis outside of our home and we are not in possession of a Registry ID Card, we may be subject to a fine of up to $100.”;
      13. m. “I understand that any person(s) who makes a fraudulent representation to a law enforcement official of any fact or circumstance relating to the therapeutic use of cannabis to avoid arrest or prosecution shall be guilty of a violation and may be fined $500, which shall be in addition to any other penalties that may apply for making a false statement to a law enforcement official or for the use of cannabis other than use undertaken pursuant to this RSA 126-X.”;
      14. n. “I understand that the protections granted by RSA 126-X for the therapeutic use of cannabis apply only within NH.”;
      15. o. “I understand that my Qualifying Patient and I must be in compliance with RSA 126-X and with the administrative rules adopted thereunder, and that the Department may revoke a Registry ID Card for any violation of any provision of RSA 126-X or the rules adopted thereunder.”; and
      16. p. “I understand that I, by possessing cannabis, and my Qualifying Patient, by using cannabis, may be denied rights and privileges by federal agencies including, but not limited to, those related to employment such as driving a commercial vehicle, those related to owning, possessing, or purchasing a firearm and ammunition, those related to federally subsidized housing, those related to immigration and naturalization, or the inability to pass a security clearance.”;
   8. (8) A signed and dated attestation that the applicant has not been convicted of a felony offense in New Hampshire or in any other state, and agreement to notify the department if convicted of a felony offense subsequent to being issued a registry ID card;

   9. (9) Signed and dated certification(s) that:

      1. a. The minor applicant is a resident of New Hampshire;
      2. b. The facts as stated in the application are accurate to the best of the designated caregiver applicant’s knowledge and belief; and
      3. c. The designated caregiver applicant understands that any false statements made on the application are punishable as unsworn falsification under RSA 641:3; and
   10. (10) A signed and dated pledge not to divert cannabis to anyone who is not allowed to possess cannabis pursuant to RSA 126-X, acknowledgement that diversion of cannabis shall result in revocation of their registry identification card, and acknowledgement that the sale of cannabis to anyone who is not a qualifying patient or a designated caregiver is punishable as a class B felony with a sentence of a maximum term of imprisonment of not more than 7 years, and a fine of not more than $300,000, or both, in addition to other penalties for the illegal sale of cannabis.
4. (d) In cases where parents share legal custody of a minor applicant, and both parents are not listed on the application, the parent submitting an application shall notify the other parent with legal custody of the minor applicant in advance of submitting the application to the department by providing to the other parent a copy of the completed application and the completed written certifications.

5. (e) In addition to the application described in (c) above, the following shall also be submitted:

   1. (1) Two written certifications, described in He-C 401.07, from 2 different providers, one of whom shall be a pediatric care provider as defined in (f) below and which shall meet the following additional requirements:

      1. a. At least one qualifying medical condition shall match between the 2 written certifications; and
      2. b. If the durations indicated on the 2 written certifications do not match, then the duration shall be the lesser of the 2 written certifications;
   2. (2) Proof of NH residency, as described in He-C 401.04(b)(3), for either the minor applicant or one of the designated caregiver applicants;
   3. (3) A fee in accordance with He-C 401.14(b)(2); and
   4. (4) In cases where a minor applicant’s legal guardian is not a custodial parent, the legal guardian shall submit with the application proof of legal guardianship.

6. (f) For the purposes of these rules, “pediatric care provider” means:

   1. (1) A provider who has a medical specialty of pediatrics, family practice or family medicine, or a pediatric subspecialty;

   2. (2) A physician associate:

      1. a. Whose collaboration agreement, if one is required under RSA 328-D:3-b, is with a physician with a medical specialty of pediatrics, family practice or family medicine, or a pediatric subspecialty;
      2. b. Who is employed as a member of a pediatric healthcare team; or
      3. c. Who is a sole practitioner who has extensive training and experience treating children from birth through young adulthood for their physical, emotional, and social healthcare needs; or
   3. (3) A provider who has extensive training and experience treating children from birth through young adulthood for their physical, emotional, and social healthcare needs.

7. (g) Providers in (f)(2) and (3) above shall complete a “Pediatric Care Provider Attestation” which includes:

   1. (1) Minor qualifying patient’s name;
   2. (2) Minor qualifying patient’s date of birth;
   3. (3) Certifying provider’s name;
   4. (4) Certifying provider’s license number;

   5. (5) For physician associates in (f)(2) above, an attestation that the provider is a licensed physician associate and:

      1. a. If required by RSA 328-D:3-b, has a collaboration agreement with a physician with a medical specialty of pediatrics, family practice or family medicine, or a pediatric subspecialty;
      2. b. Is employed as a member of a pediatric healthcare team; or
      3. c. Is a sole practitioner who has extensive training and experience treating children from birth through young adulthood for their physical, emotional, and social healthcare needs;
   6. (6) For providers in (f)(3) above, an attestation that the provider is a provider who has extensive training and experience treating children from birth through young adulthood for their physical, emotional, and social healthcare needs; and
   7. (7) Certifying provider’s dated signature.

8. (h) The documents in (c), (e), and (g) above shall be submitted to:

   NH Department of Health and Human Services

   Therapeutic Cannabis Program

   29 Hazen Drive

   Concord, NH 03301

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