Forms

The purpose of this form is to obtain medical records from a physician that you have seen from within the last 12 months for one of the Arizona State identified qualifying conditions. Please verify the name entered on this form, matches the name on your Arizona State Issued Identification or US Passport Book.

The information that is filled out on this form will be entered onto your Arizona Medical Marijuana card application. Please verify the name entered on this form, matches the name on your Arizona State Issued Identification or US Passport Book.
WARNING: If the name on this form does not match the name on your ID, your application will NOT be approved by the Arizona State Medical Marijuana Program.

(New or Renewal)

This form acknowledges that you, the patient, will not share cannabis with non-card holders. Please verify the name entered on this form, matches the name on your Arizona State Issued Identification or US Passport Book.
WARNING: If the name on this form does not match the name on your ID, your application will NOT be approved by the Arizona State Medical Marijuana Program.

Image of Dr. Sonya Johnson

Dr. Alexandra Porter

Image of Dr. Jasmine May

Dr. Jasmine May

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Dr. Aiyana Brown

Image of Dr. Sonya Johnson

Dr. Sonya Johnson

Disclaimer

Naturopathic Doctor Visit Insurance Reimbursement Disclaimer:
Natural Healing Care Center currently does not accept insurance for naturopathic services. However, we can assist with out-of-network deductions by providing an ICD Code for a New Patient Problem Focus Exam. By providing the insurance company with the ICD Code, it will allow them to deduct full or partial costs depending on the financial policies of the provider. The patient may personally contact their insurance company to inquire if they can accept the following ICD Code listed below.

ICD Code:
99201

Additional Reimbursement Options:
At the time of the naturopathic visit, NHCC will provide each patient with an itemized receipt of the services rendered, which the patient can provide to their insurance company for full or partial reimbursement. If there are any additional inquiries or questions involving insurance or coverage or about our licensed naturopathic physicians, please contact the NHCC office directly!