Application for Financial Assistance:
Just Say Yes! 1001 Cedar Corner Rd. Suite D1 Perryville, MD 21903 | 410-642-2710
Street Address Line 2
State / Province
Postal / Zip Code
Do you currently have your Medical Cannabis Card?
Have a patient ID number, but not my certification
Do you have Medicaid?
Are you a Veteran?
This includes all household members.
This includes income for all members of your household.
Please read each statement and check the box indicating that you understand each statement.
I understand that I will be required to provide proof of income for myself and all members of my household.
I understand that funds are limited and I am not guaranteed financial assistance and may be placed on a waiting list.
I understand that I will be required to provide proof of address.
I understand that I may be required to provide proof of dependants(Ie: birth certificates, custody agreement.)
I confirm that all information provided in this application is true and accurate.
What is your main diagnosis?
Should be Empty:
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