Healthcare Marijuana LLC Agreement

HEALTHCARE MARIJUANA LLC AGREEMENT

This Healthcare Marijuana LLC Agreement ("Agreement") is entered into between Patient and Healthcare Marijuana LLC for the provision, dispensing, and management of medical cannabis in accordance with applicable law and the terms set forth herein.

Parties and Effective Date

Patient Name:

Healthcare Marijuana LLC (Provider) Name:

Effective Date:

Patient Information

Male    Female    Other/Prefer not to say

Insurance & Authorization

Medical History

Services, Use, and Consent

Provider will evaluate, dispense, and manage the patient’s medical cannabis regimen consistent with the patient’s qualifying condition, physician recommendation, and applicable law. The patient authorizes Provider to dispense medical cannabis products, provide dosing guidance, and maintain records necessary for treatment and compliance.

Patient acknowledges that use of medical cannabis carries risks, including but not limited to impairment, dependence, cognitive effects, and interactions with other medications. Patient has had the opportunity to discuss risks and benefits and freely consents to receive medical cannabis from Provider. Patient retains the right to withdraw consent at any time by providing written notice to Provider.

Patient authorizes Provider to communicate with the patient's recommending physician and other healthcare providers as necessary for the safe administration and monitoring of medical cannabis therapy. Patient also authorizes Provider to obtain relevant medical records for ongoing care.

Consent to electronic communications and prescriptions: Patient consents to receive communications, records, and electronic prescriptions related to medical cannabis from Provider.

Fees, Billing, and Payment

Fees for evaluation, dispensing, and related services will be charged to Patient. Patient agrees to pay Provider's fees, including product costs and any applicable dispensing fees. If applicable, insurance benefits may be billed on Patient's behalf but Provider makes no guarantee of coverage or reimbursement.

Confidentiality & HIPAA Authorization

Provider will maintain medical records and protected health information in accordance with applicable privacy laws. By signing below, Patient authorizes Provider to use and disclose protected health information for treatment, payment, and healthcare operations and acknowledges receipt of Provider's privacy practices as provided.

HIPAA Authorization: Patient authorizes release of necessary medical information to providers, pharmacies, and payors as required for care and payment.

Representations, Warranties, Indemnity

Patient represents and warrants that the information provided in this Agreement and accompanying documentation is true, complete, and accurate. Patient will comply with all use, storage, and transportation requirements under applicable law. Patient agrees to indemnify, hold harmless, and defend Provider and its officers, agents, and employees from any claims, liabilities, damages, or expenses arising from Patient's breach of this Agreement or misuse of medical cannabis.

Limitation of Liability

To the maximum extent permitted by law, Provider's liability for damages arising out of or related to this Agreement, whether in contract, tort, or otherwise, shall be limited to direct damages and shall not exceed the amounts paid by Patient to Provider under this Agreement in the twelve (12) months preceding the event giving rise to liability. Provider shall not be liable for consequential, incidental, special, or punitive damages.

Term, Termination, and Amendment

This Agreement remains in effect until the authorization expiration date unless earlier terminated by either party upon written notice. Provider may suspend or terminate services immediately where continued provision would violate law or create a risk to health or safety. This Agreement may be amended only by a written instrument executed by both parties.

Governing Law and Dispute Resolution

This Agreement shall be governed by and construed in accordance with the laws of the state in which Provider is licensed, without regard to conflict of law principles. Parties agree to seek resolution of disputes first through good-faith negotiation. If unresolved, disputes shall be resolved by binding arbitration conducted in the county of Provider's principal place of business unless otherwise agreed in writing.

Notices

Notices required or permitted under this Agreement shall be in writing and delivered to the addresses provided in this Agreement or to such other address as a party designates in writing. Delivery may be by hand, certified mail, or any commercial courier service.

Severability and Entire Agreement

If any provision of this Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and effect. This Agreement constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior representations, negotiations, and agreements, whether written or oral.

Acknowledgment and Certification

By signing below, Patient certifies that Patient is at least 18 years of age (or the age required by law), that the information provided is accurate, that Patient has disclosed all relevant medical history, and that Patient understands and accepts the risks and conditions of treatment with medical cannabis. Provider certifies that it is duly licensed to provide the services described herein and will exercise reasonable professional judgment in the delivery of care.

Sign Now