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Healing Leaf Wellness Center  

810-969-4710

Cannabis Regulatory Agency of Michigan 

CRA Application


Healing Leaf Wellness Center

814 S Main St Ste. 4

Lapeer, MI 48446

810-969-4710

HIPAA COMPLIANT AUTHORIZATION

I authorize you to discuss my protected health information with Dr. Brian Beck and his staff at The Healing Leaf Wellness Center. I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my knowledge. I understand a covered entity may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization when the prohibition on conditioning the authorization in 45 CFR164.508 (b)(4) applies. I am providing this authorization voluntarily and have been required to give it to obtain treatment. I understand that I may revoke this authorization at any time except to the extent that the action has already been taken in reliance upon it before it is delivered. If I do not revoke it this authorization will expire in one year from the date in which I signed it. I understand that the information disclosed through this authorization may be subject to re-disclosure and no longer protected by the privacy protections associated with HIPAA and CFR 164.50. This document shall be governed by the health insurance portability and accountability act of 1996 (HIPAA), Pub L No 104-191, MCL 333.26261 et seq. However, I intend it to be honored in any jurisdiction where it is presented and for other jurisdictions to refer to Michigan law and HIPAA to interpret to determine the validity and enforceability of this document. Photocopies or facsimile reproductions of this signed authorization shall be treated as original counterparts. 

May 2, 2025


PATIENT CONSENT AND WAIVER OF LIABILITY 

I agree not to make any legal claim or complaint or commence any proceeding against Dr. Brian Beck, D.O., Healing Leaf Wellness Center, or the Center For Compassion, LLC (hereinafter referred to as “Physician”), for providing me with a physician certification as required by the Michigan Medical Marihuana Act, MCL 333.26421 et seq. 

I am hereby giving voluntary informed consent to treatment with Medical Cannabis. I understand that there are other treatment options and I am not obligated to seek an evaluation from this Physician. I release the Physician from any and all actions, causes of actions, claims, complaints, and demands for damages, loss of life, injury, economic or employment loss, damage to reputation or character, termination or service/care by another healthcare professional, or whatsoever arising directly or indirectly as a result of my Physician’s “Certification” and Medical Cannabis Use registration with the State of Michigan, and my use of Medical Cannabis. The physician is not liable in the event you have an adverse reaction to any and all marijuana products.

I hereby affirm that I am assuming all risks associated with the use of medical marihuana, both foreseeable and unforeseeable, that may occur now or anytime in the future. I understand that the Physician Certification is not a prescription or an order for treatment; it is only a document to confirm my diagnosis to the Michigan Department of Licensing and Regulatory Affairs (LARA). We are not liable for denials from LARA, please check all your paperwork thoroughly.

I understand that it is my responsibility to see the physician in a bona fide patient-doctor consultation to assess the possible continuance of medical marihuana use beyond the term of approval. I acknowledge that the Physician will not testify on my behalf for a MCL 333.26424 Section 4 defense, MCL 333.26428 Section 8 defense, or any other medical necessity defense related to any criminal cannabis charges or other criminal or civil matters, especially if you have not completed your one-year follow up with the physician. Furthermore, I release the Physician from all subpoenas, interrogatories, questions, or testimonies related to any criminal cannabis charges or other criminal or civil matters. Your Medical Marijuana Certification and state-issued Medical Marijuana card is all the courts need if they require verification. The Doctor will not assess you for criminal probation, Social Security or Secretary of State assessments. 

 This release of liability is to be binding on my heirs, executors, and assignees. I have read, understand, and agree with all the statements in this form.

May 2, 2025


The Michigan Medical Marihuana Act Bona Fide Physician-Patient Relationship

Your annual Follow-up appointment

Registering as a qualified patient under the Michigan Medical Marihuana Act (MMMA) requires a “bona fide physician-patient relationship,” as defined in the act by P.A. 12 or 2012, the December 2012 legislative amendments to the act became effective April 1, 2013.

“Bona-Fide physician relationship” means a treatment or counseling relationship between a physician and patient in which all of the following are present.

  1. The physician has reviewed the patient's relevant medical records and completed a full assessment of the patient's full medical history and current medical condition, including a relevant, in-person, medical evaluation of the patient.
  2. The physician has created and maintained records of the patient's condition in accord with medically accepted standards.
  3. The physician has a reasonable expectation that he or she will provide follow-up care to the patient to monitor the effectiveness of the use of medical marihuana as a treatment of the patient's debilitating medical condition.

These criteria are used both by physicians in the practice of recommending medical marihuana to qualifying patients, and in the interpretation of the eligibility for the legal protections of the act by judges, prosecutors, and ultimately jurors, when determining if the parent or caregiver being prosecuted is qualified to use the affirmative defense. In most cases that lead to parent or caregiver arrest, the affirmative defense is the only way to force the courts to reach a reasonable decision.

The act now defines what a bona-fide patient relationship means, and mandates a REQUIRED ANNUAL follow-up appointment.

May 2, 2025

Please select who will be participating...
AdultMinor
Continue
What type of application are you seeking today?
Tell us more about your needs *
First time Applicant
Renewal Certification
Health Consultation or Annual follow-up
Are you seeking Online or Paper Application?
CRA Application type (State of Michigan bi-annual fee of $40 is separate)*
Online- $129 Same day approval
Paper- $99
Paper with a Caregiver- $99
First Patient's Name

First Name*

Middle Name

Last Name*

Phone*
By checking this box, you agree to receive text message updates from the business who owns this Smartwaiver form. Msg & data rates may apply. Msg frequency is recurring. Reply STOP to opt out.
First Patient's Date of Birth*
First Patient's Information

 Do you have an account with Michigan’s Licensing and Regulatory Affairs (LARA) already? 


-if yes, please list the email address used and skip the next box

Email Address (that you have access to)

Password for MRA website-


Please use old password if you have a previous account. If you're making a new account, your password must be at least 8 characters long and include: upper & lower case letters, a number, & a special character.

Security Question-


Please use old security questions if you already have an account.

Answer To Your Security Question -  


Please use the old security answer if you already have an account.

If you do not receive your new card within 14 days call 517-284-8599

You can use this login information to change your address or order replacement cards

MEDICAL HISTORY AND CURRENT MEDICAL CONDITIONS


OCCUPATION:

FAMILY DOCTOR:

DOCTOR’S PHONE:
Are you a disabled military veteran? *
No
Yes
Are you on SSDI or SSI? *
No
Yes

LIST MEDICATIONS (or attach list):

List Allergies:

List Surgeries/Procedures and their approximate date/year:

Please check all of your qualifying conditions? If your condition is not listed, check the symptoms that qualify you and fill your specific medical condition into the box below this section. At least one box should be selected.

Category A

Cancer
Glaucoma
HIV Positive
AIDS
Hepatitis C
Amyotrophic Lateral Sclerosis
Crohn’s Disease
Agitation of Alzheimer’s Disease
Nail Patella

Category B

A chronic or debilitating disease or medical condition or its treatment that produces 1 or more of the following:

Cachexia or Wasting Syndrome
Severe and Chronic Pain
Severe Nausea
Seizures (including but not limited to those characteristics of epilepsy)
Severe and Persistent Muscle Spasms (including but limited to those characteristics of multiple sclerosis)

Category C

Post Traumatic Stress Disorder
Obsessive Compulsive Disorde
Arthritis
Rheumatoid Arthritis
Spinal Cord Injury
Colitis
Inflammatory Bowel Disease
Ulcerative Colitis
Parkinson’s Disease
Tourette's Syndrome
Autism
Chronic Pain
Cerebral Palsy

If your condition is not listed above write symptoms here
ARE YOU EXPERIENCING SIDE EFFECTS AS A RESULT OF DRUGS OR MEDICATIONS FOR YOUR CONDITION?*
No
Yes
DO YOU HAVE DIABETES? *
No
Yes
DO YOU HAVE MIGRAINE HEADACHES?*
No
Yes
DO YOU HAVE OVERLY PAINFUL PREMENSTRUAL SYNDROME?*
No
Yes
WOULD YOU LIKE TO SCHEDULE A CANNABIS CONSULTATION FOR DOSAGE AND USE RECOMMENDATIONS? *
No
Yes
First Patient's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Patient's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Upload a copy/picture of your State of MI Identification card or your Driver's License
  
Proof of Identification *
Valid file types: JPG, GIF, PNG, and PDF
Medical Documents or previous MMMP card- Not necessary, but helpful if able.
  
Upload a picture of your Diagnosis or picture of previous Medical Marijuana Card
Valid file types: JPG, GIF, PNG, and PDF
How did you hear about our service?
Click to customize checkboxes *
Friend/Referral
Google
Facebook
Internet
Returning Patient
Other
Method of Payment-

Your payment will be processed in two parts if doing an Online State Application.

You will see billing from HE Management, llc for Physician billing and LARA - State of Michigan for the State fee.


Name on Credit Card *

Credit Card # *

Exp. Date *

Security Code *

Zip code of Billing address *
By checking this box, you are authorizing us to bill the credit card provided. *
Yes
Birth Certificate (for Minors ONLY)
  
Submit a picture of Minor's Birth Certificate
Valid file types: JPG, GIF, PNG, and PDF
Guardianship/Court Papers (for Minors ONLY)
  
Upload a picture of guardianship papers if applicable or if your last name does not match your child's Birth Certificate
Valid file types: JPG, GIF, PNG, and PDF
Anything else...

Please include any other information here that you think might be needed or helpful.

Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.

If you are an appointed guardian, you must submit the proper court document and/or a birth certificate for the minor's application. 



By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

 Do you have an account with Michigan’s Licensing and Regulatory Affairs (LARA) already? 


-if yes, please list the email address used and skip the next box

Email Address (that you have access to)

Password for MRA website-


Please use old password if you have a previous account. If you're making a new account, your password must be at least 8 characters long and include: upper & lower case letters, a number, & a special character.

Security Question-


Please use old security questions if you already have an account.

Answer To Your Security Question -  


Please use the old security answer if you already have an account.

If you do not receive your new card within 14 days call 517-284-8599

You can use this login information to change your address or order replacement cards

MEDICAL HISTORY AND CURRENT MEDICAL CONDITIONS


OCCUPATION:

FAMILY DOCTOR:

DOCTOR’S PHONE:
Are you a disabled military veteran? *
No
Yes
Are you on SSDI or SSI? *
No
Yes

LIST MEDICATIONS (or attach list):

List Allergies:

List Surgeries/Procedures and their approximate date/year:

Please check all of your qualifying conditions? If your condition is not listed, check the symptoms that qualify you and fill your specific medical condition into the box below this section. At least one box should be selected.

Category A

Cancer
Glaucoma
HIV Positive
AIDS
Hepatitis C
Amyotrophic Lateral Sclerosis
Crohn’s Disease
Agitation of Alzheimer’s Disease
Nail Patella

Category B

A chronic or debilitating disease or medical condition or its treatment that produces 1 or more of the following:

Cachexia or Wasting Syndrome
Severe and Chronic Pain
Severe Nausea
Seizures (including but not limited to those characteristics of epilepsy)
Severe and Persistent Muscle Spasms (including but limited to those characteristics of multiple sclerosis)

Category C

Post Traumatic Stress Disorder
Obsessive Compulsive Disorde
Arthritis
Rheumatoid Arthritis
Spinal Cord Injury
Colitis
Inflammatory Bowel Disease
Ulcerative Colitis
Parkinson’s Disease
Tourette's Syndrome
Autism
Chronic Pain
Cerebral Palsy

If your condition is not listed above write symptoms here
ARE YOU EXPERIENCING SIDE EFFECTS AS A RESULT OF DRUGS OR MEDICATIONS FOR YOUR CONDITION?*
No
Yes
DO YOU HAVE DIABETES? *
No
Yes
DO YOU HAVE MIGRAINE HEADACHES?*
No
Yes
DO YOU HAVE OVERLY PAINFUL PREMENSTRUAL SYNDROME?*
No
Yes
WOULD YOU LIKE TO SCHEDULE A CANNABIS CONSULTATION FOR DOSAGE AND USE RECOMMENDATIONS? *
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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