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

3. (c) The patient applicant’s legal guardian shall include the following on the “Guardianship Patient Application” form:

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

   2. (2) The following patient applicant information:

      1. a. Full name;
      2. b. Date of birth;
      3. c. Gender;
      4. d. Optional telephone number;
      5. e. Mailing address; and
      6. f. Physical address, if different than mailing address, except that if the patient 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 patient applicant; and
      6. f. Physical address, if different than the patient applicant;

   4. (4) The following information about the patient applicant’s certifying provider:

      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 provider to the department if further information about the patient applicant’s qualifying medical condition or written certification is required by the department;

   6. (6) 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 an appeal request 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 Department 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 New Hampshire.”;
      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.”;
   7. (7) 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;

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

      1. a. The patient 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;
   9. (9) Signed and dated pledge(s) 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; and

   10. (10) Voluntary demographic information, as follows:

       1. a. Race and ethnicity;
       2. b. Veteran status;
       3. c. Employment and income;
       4. d. Public assistance;
       5. e. Education;
       6. f. Health insurance;
       7. g. Marital status; and
       8. h. Language proficiency.
4. (d) In cases where co-guardians share legal custody of an adult patient applicant, and both co-guardians are not listed on the application, the guardian submitting an application shall notify the other guardian with legal custody of the adult patient applicant in advance of submitting the application to the department by providing to the other guardian a copy of the completed application and the completed written certification.

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

   1. (1) A written certification, described in He-C 401.07;
   2. (2) Proof of NH residency for the patient applicant, as described in He-C 401.04(b)(3), except that if this information is not available for the patient applicant, it shall be submitted for one of the designated caregiver applicants;
   3. (3) A fee in accordance with He-C 401.14(b)(5); and
   4. (4) Proof of legal guardianship for each designated caregiver applicant listed on the application.

6. (f) The documents in (c) and (e) 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 #2 at part heading for He-C 401) #13220, eff 7-1-21; ss by #13567, eff 5-1-23