State of Illinois
Illinois Department of Public Health
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Page 6 of 6
Printed by Authority of the State of Illinois
IOCI 20-446
State of Illinois
Illinois Department of Public Health
Illinois Medical Cannabis Patient Program
Application for Registry Identification Card
Veterans Receiving Medical Services at a VA Facility
*** DO NOT COMPLETE THIS FORM IF YOU ARE NOT A VETERAN ***
Veterans receiving health care at a VA facility do not need to provide the health care professional confirmation of diagnosis of terminal
illness on page 3, but must instead provide the following information found on My HealtheVet.
❑ Medical records from the VA facility for the last 12 months.
• VA appointments
• VA medication history
• VA problem list
• VA admissions and discharges
• VA progress notes
❑ Copy of your DD-214 showing dates of service and character of service (type of discharge)
ATTESTATION OF TERMINAL ILLNESS
I __________________________________________________________
hereby certify that I receive medical services from a VA facility
and have been diagnosed with a terminal illness of _________________________________________________________ (insert name of
disease or illness) with a life expectancy of six (6) months or less. Under penalties including, but not limited to, perjury, and administrative
action, I declare that I have examined the application, all supporting documents submitted by me in connection therewith, and all statements
contained therein, and to the best of my knowledge, they are true, correct, and complete.
_____________________________________________________________ ____________________________
Signature (no stamps accepted) – Sign in blue ink only Date of signature (mm/dd/yyyy)
State of Illinois
County of ___________________.
Signed (or subscribed or attested) before me on _______________ (date)
by _______________________________________________ (name of person).
(seal)
_________________________________________________
Signature of Notary Public
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