A Qualified California Cooperative Corporation
1. MEMBERSHIP APPLICATION & AUTHORIZATION TO RELEASE INFORMATION
As a qualified patient protected by California Law, Health and Safety Code § 11362.1 et seq., and in conjunction with California State and Senate Bill 420, you are required to read and agree to the following statements to become a member of T.C. Method, herein “the Cooperative.” Please review the following acknowledgements and understand that these acknowledgements are for the protection of the Cooperative.
I consent to the benefits provided by the Cooperative and agree to abide by the Bylaws, rules, and regulations of the Cooperative. I agree that as a member of the Cooperative any and all medical cannabis and cannabinoids provided to me by T.C. Method shall not be distributed by me in any unauthorized or illegal manner.
I was diagnosed with a “serious medical condition” that substantially limits my ability to conduct one or more major life activities for which the use of marijuana provides relief. My medical authorization and prescription is hereby provided with this application and made part of this document. I agree to provide updated renewals as needed. As a member, I appoint and designate this Cooperative, and their representatives, as my true and lawful agents for the limited purpose of assisting in obtaining medical marijuana. I understand this means that T.C. Method may be required to cultivate possess, transport, and distribute my medication to me; and I grant them the authority to do so.
I have been informed and understand that acceptance of my application is at the Cooperative’s discretion and that the Cooperative reserves the right to refuse my membership.
I acknowledge that my contributions are used to ensure continued operation of the Cooperative and are applied toward future harvests of the Cooperative’s medicine as well as other items of overhead and operating costs. The medicines I acquire during my membership are indicative of what I will require in the future and my contributions will be used to produce that amount of medicine on my behalf. As a qualified medical cannabis patient under the Compassionate Use Act, and the Medical Cannabis Program Act, I intend to associate with the members of the medical Cannabis cooperative, being hereby formed, in part, through this agreement, in order to cooperatively cultivate Cannabis for medical purposes pursuant to the Medical Cannabis Program Act, which includes in part, California Health and Safety Code § 11362.775 and Section I (b)(3) of the un-codified portion of the Medical Cannabis Program Act, which was enacted by the People of the State of California, in part, in order to promote uniform and consistent application of the Compassionate Use Act among counties within the state, and to enhance the access of patients and caregivers to medical Cannabis through cooperative cultivation projects.
I understand that all contributions made to T.C. Method are to be used to reimburse for actual expenses and reasonable costs for the administration of the Cooperative. Furthermore, all contributions are for the continued operation of the Cooperative and that any said contribution in no way constitutes a commercial promotion sale of any item.
I agree to contact T.C. Method. immediately if there are any changes to my address, phone number or physician, as well as any changes to the validity of my California ID or my physician’s recommendation or DHS Card.
By clicking this checkbox, I understand this is a bi-lateral Membership Agreement and either I or T.C. Method may terminate the Agreement at any time in writing, without notice or reason, and the other party to the Agreement has absolutely no recourse or basis to reinstate the Agreement or any cause of action. Any amount that I may owe the Cooperative for any reason is due and payable upon my withdrawal from the Cooperative.
By clicking this checkbox, I understand that as a qualified patient I have the California State Constitutional right to use medical cannabis if recommended by a licensed medical physician in good standing. Furthermore, I acknowledge and accept as true that medical cannabis, although an effective therapeutic agent, is illegal under federal law and thereby membership and the submission of an application to join the Cooperative are acts inconsistent with federal law.
By clicking this checkbox, I hereby authorize my recommending physician to release information regarding my diagnosis and condition to T.C. Method.
2. MEMBER’S SIGNATURE MEMBERSHIP GUIDELINES
T.C. Method, herein “the Cooperative,” is dedicated to providing the highest quality of service to our members. The Cooperatives was created in order for members to collectively associate and cultivate Cannabis for medical purposes.
We require our members to follow the guidelines below. They are designed to provide a safe and secure atmosphere for everyone. We practice a “Good Neighbor Policy” with our community and work hard to establish positive relationships with our neighbors, the city, and the police department. Please be respectful of your neighbors and their rights to privacy and property. Remember, not everyone shares our opinion about medical marijuana.
ALL MEMBERS MUST BE QUALIFIED PATIENTS BEFORE MEMBERSHIP IN THE COOPERATIVE WILL BE ACCEPTED. You must have the original copy of your doctor’s recommendation and a valid California ID, Driver’s License, or State Medical Marijuana Identification Card at the time of registration and delivery for continued access to our members’ services.
You must be at least eighteen (18) years of age. You may NEVER SELL or otherwise distribute medication you obtain from the Cooperative. If you do so, your membership will permanently REVOKED. If you disturb the Cooperative of threaten violence on any person or staff, your membership will be REVOKED. For your safety, our delivery concierge places all medication in a bag or out of sight when delivering medication to you. The Cooperative reserves the right to refuse service or revoke membership to members who violate our guidelines or bylaws. I have read and understand the above guidelines and agree to abide by these guidelines when I order a delivery from T.C. Method.
3. HIPAA/CMIA AUTHORIZATION
I am either the Patient named above or the Patient’s legally authorized representative. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C § 1320d and 45 C.F.R. § 160-164, and/or information governed by the California Confidentiality of Medical Information Act (“CMIA”) Cal. Civ. Code §§ 56-56.37. Specifically, this release authority complies with the valid authorization requirements of 45 C.F.R. § 164.508(c). Pursuant to HIPAA and/or CMIA, I authorize and direct any physician, health care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or other covered health care provider, any insurance company, and the Medical Information Bureau, Inc., or other health care clearinghouse that has provided treatment or services to me or that has paid for or is seeking payment from me for such services, to give, disclose, and release, with restriction, all of my individually identifiable health information and medical records regarding my past, present, and future medical or mental health condition, to include all information relating to the diagnosis and treatment of sexually transmitted diseases, mental illness, and drug or alcohol abuse to T.C. Method.
The purposes of the usage and disclosure shall include determinations regarding my qualification to use medical marijuana and monitoring my health care to protect my legal rights where I reside. I understand that, with certain exceptions, I have the right to revoke this Authorization at any time. If I want to revoke this Authorization, I must do so in writing. The procedure for how I may revoke this Authorization, as well as the exceptions to my right to revoke will be performed in accordance with applicable federal law and any applicable policy of my health care provider.
I understand that I may refuse to sign this Authorization. If I refuse to sign, I understand that I cannot become a member of this cooperative. I also understand that my health care provider cannot deny or refuse to provide treatment, payment, and enrollment in a health plan or eligibility of benefits if I refuse to sign this Authorization.
I understand that, once information is disclosed pursuant to this Authorization, it is possible that it will no longer be protected by applicable federal medical privacy law and could be re-disclosed by the person or agency that receives it; however, I do not authorize such secondary disclosure. The authority given to the persons or parties named above shall supersede any prior agreement that I may have made with my healthcare providers to restrict access to or disclosure of my individually identifiable health information. The authority given has no expiration date and shall expire only in the event that I revoke the authority in writing and deliver it to my health care provider. I have read and understand the information in this Authorization form.