(c) Application. — A patient or a caregiver may apply, in a form and manner prescribed by the bureau, for issuance or renewal of an identification card. A caregiver must submit a separate application for issuance or renewal. Each application must include:
- (1) The name, address and date of birth of the patient.
- (2) The name, address and date of birth of a caregiver.
- (3) The certification issued by the practitioner.
- (4) The name, address and telephone number of the practitioner and documentation from the practitioner that all of the requirements of subsection (a), section three, article four of this chapter have been met.
- (5) A $50 processing fee. The bureau may waive or reduce the fee if the applicant demonstrates financial hardship.
- (6) The signature of the applicant and date signed.
- (7) Other information required by the bureau.