Beach Health Center Secure Patient Renewal Form
Your personal data privacy is protected through our system compliant with HIPAA. HIPAA secure form for your renewal information. You will be emailed a QuickBooks payment invoice for $40, once paid we will print and text you a picture of your med card. Beach Health Center is open Monday - FRIDAY 10am - 6pm, SATURDAYS NOON - 6PM. Closed Sundays. Renewals are processed 10am - 5pm Monday - FRIDAY, SATURDAYS NOON - 5PM.
Patient Information
Patient LEGAL Name as seen on your ID, please recheck your name for accuracy
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First Name
Last Name
DATE OF BIRTH MM/DD/YYYY
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Month
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Day
Year
Date
Phone Number - please recheck number for accuracy, YOU WILL BE TEXTED YOUR MED CARD AFTER INVOICE PAYMENT
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Area Code - (like 207,518 etc)
Phone Number
Mailing Address - your actual mailing address for the physical med card to be sent to
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Street Address
apartment or unit if needed
City
State / Province
Postal / Zip Code
Patient E-Mail
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Maine State License / ID Upload
WE HAVE TO SEE THAT YOU STILL HAVE A VALID MAINE STATE DRIVERS LICENSE OR ID EVERY YEAR.
Please attach your VALID MAINE STATE ID / DRIVERS LICENSE (temporary MAINE License paperwork is acceptable pictured with your voided out of state or expired license. IF YOU DO NOT HAVE A MAINE STATE LICENSE OR ID YOU ARE NOT ELIGIBLE FOR A MED CARD IN MAINE )
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Browse Files
WE CANNOT ACCEPT PASSPORTS, MAIL, OR OUT OF STATE LICENSE OR IDS. ONLY MAINE STATE LICENSE OR ID IS ACCEPTABLE FOR A MEDICAL CARD IN MAINE
Cancel
of
Patient Agreement & Consent
* Please sign below that you have read, understood, and answered the above questions truthfully to the best of your knowledge.
Please read and check each item:
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I understand that Beach Health Center will not send my medical information or card status to anyone unless I send a written request to do so
The Maine Medical Cannabis Program is protected by the medical privacy act. I understand that no one knows I have a Maine Medical Cannabis Card unless I tell them or show them my card. I understand that there is no registry in Maine.
I attest that I have attached a valid Maine state license or ID that is in my possession and is not revoked, surrendered, or lost.
I am requesting to renew my Maine Medical Cannabis Certificate, I understand Beach Health Center will email me a secure invoice for payment
Patient Signature
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Today's Date
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Month
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Day
Year
Date
How would you like to be notified next year that your renewal is coming due? you may choose more than one
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email
mail
none
NEW OPTION:
MAIL THE NEW CARD TO ME
DO NOT MAIL THE CARD TO ME: I ONLY WANT THE "DIGITAL" MED CARD THE IS EMAILED TO ME AFTER PAYMENT. THE DIGITAL MED CARD IS VALID IN PICTURE FORM FROM ISSUE DATE TO EXPIRATION DATE.
YOU WILL BE EMAILED A SECURE QUICKBOOKS INVOICE FOR PAYMENT AFTER SUBMISSION. MONDAY - FRIDAY 10AM - 5PM, SATURDAYS NOON - 5PM. PLEASE DO NOT PAY THE INVOICE UNTILL YOU WANT THE MED CARD PROCESSED. WE CANNOT PRE OR POST DATE MED CARDS THEY ARE DATED FOR THE SAME DAY THEY ARE PROCESSED AND EXPIRE 1 YEAR LATER. MED CARDS ARE PROCESSED WITH-IN 24 HOURS OF INVOICE PAYMENT
WE ARE ON VACATION FROM 5PM THURSDAY 3.26.26 UNTIL 10:30AM TUESDAY 4.7.26. ANY SUBMISSIONS DURING THAT TIME WILL BE FOLLOWED UP UPON OUR RETURN IN THE ORDER THEY CAME IN
SUBMIT
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