APPLICATION

All patients and legal representatives must complete an application.

Download Application

Along with the application you must submit:

• A copy of your Florida driver license, Florida identification card, or other proof of residency.
• A $75 check or money order (application fee) made out to Florida Department of Health.
• A passport-style, color photograph (2×2 inches in size) taken within the 90 days immediately preceding application.

CHILDREN

If you are applying for a child under the age of 18, you must also include:

• A designated legal representative.
• A Compassionate Use Registry Identification Card Legal Representative Application.
• A copy of the parent’s or designated legal representative’s proof of residency.

Download Legal Representative Application