Patient application.

(a) The commissioner shall develop a patient application for enrollment into the registry program. The application shall be available to the patient and given to health care practitioners in the state who are eligible to serve as health care practitioners. The application must include:

(1) the name, mailing address, and date of birth of the patient;

(2) the name, mailing address, and telephone number of the patient's health care practitioner;

(3) the name, mailing address, and date of birth of the patient's designated caregiver, if any, or the patient's parent deleted text begin or deleted text end new text begin , new text end legal guardian new text begin , or spouse new text end if the parent deleted text begin or deleted text end new text begin , new text end legal guardian new text begin , or spouse new text end will be acting as a caregiver;

(4) a copy of the certification from the patient's health care practitioner that is dated within 90 days prior to submitting the application which certifies that the patient has been diagnosed with a qualifying medical condition and, if applicable, that, in the health care practitioner's medical opinion, the patient is developmentally or physically disabled and, as a result of that disability, the patient deleted text begin is unable to self-administer medication deleted text end new text begin requires assistance in administering medical cannabis new text end or deleted text begin acquire deleted text end new text begin obtaining new text end medical cannabis from a distribution facility; and

(5) all other signed affidavits and enrollment forms required by the commissioner under sections 152.22 to 152.37 , including, but not limited to, the disclosure form required under paragraph (c).