I hereby authorize the use and disclosure of the medical information contained in the medical recommendation of my physician for medical marijuana, for the purposes of confirming that (1) I am a qualified patient under Health and Safety Code
§11362.5 and 11362.7 et seq., (2) the recommendation is a true and correct copy of the record contained in my medical records maintained by the physician’s office, and (3) I am a member of the nonprofit medical marijuana patients collective, TYBC, Inc., and have authorized the collective and its members to cultivate, process, transport, and store medical marijuana on my behalf, and to distribute medical marijuana to me and other qualified patients and caregivers who join the Collective.
I understand that by signing this authorization:
I authorize the use and disclosure of my individually identifiable personal information as described above for the purposes listed.
I have the right to withdraw permission for the release of my information. If I sign this authorization to use and disclose information, I can revoke that authorization at any time except if you have already acted because of my permission. The revocation must be made in writing and will not affect information that has already been used or disclosed.
I have the right to inspect and receive a copy of this authorization.
I am signing this authorization voluntarily. I have had an opportunity to review this form, and confirm that it accurately reflects my wishes.
I further understand that a person to whom records and information are disclosed pursuant to
this authorization may not further use or disclose the information without my permission.
The collective’s policy on privacy is to not disclose the name or identity of any patient other than in the course of confirmation of the recommendation from my physician regarding the medical use of marijuana and as may be necessary to establish that the cultivation, processing, transportation, storage and dispensing of medical marijuana to me is authorized under California medical marijuana laws. This authorization shall terminate on the expiration of my medical recommendation unless terminated sooner in writing by me.