Note: Refer to the Registration Instructions when completing this form.

Is the patient under age 18?

Yes No

Is the patient in hospice care?

Yes No

Please check boxes to confirm that you have the following information/documents to register a minor patient:

Caregiver ID Number
Your Caregiver ID Number was provided in your caregiver registration approval email. If you registered, but do not know your Caregiver ID Number, please contact MMCC. If you have not registered yet, please register. Please note that the caregiver must be a legal guardian of the minor patient.
The last four digits of the patient’s SSN
You must provide the last four digits of the patient’s SSN to register a patient.
An electronic, notarized copy of the Minor Patient Form
Please download the Minor Patient Form, complete the form, get it notarized, then scan or take a clear picture of the completed form.
An electronic copy of proof of guardianship for the minor patient
You must upload a copy of the minor patient’s birth certificate, adoption papers, or a court order awarding guardianship.
An electronic copy of the front and back of your government photo ID AND either
(1) proof of Maryland address or (2) name and address of the Maryland medical facility where patient is being treated.
The caregiver must upload a copy of his/her valid US government-issued photo ID, such as a driver’s license, passport or military ID.
An electronic copy of a current photo of the patient
This must be a clear, color photo of the patient’s unobscured face taken within the last six months to reflect the patient’s current appearance with a plain white or off-white background. The patient must be directly facing the camera and should have a neutral facial expression or natural smile with both eyes open. Generally, the photo should look like a driver’s license or passport photo. The file must be an image (.jpg, .png or .gif) no larger than 3 MB in size and may not be digitally enhanced or altered in a way that changes the patient’s appearance. Please refer to the Registration Instructions for more information concerning the photo requirements.

If your photo does not meet our guidelines, your application will be returned.
An example of an acceptable photo is shown here.
A valid, accessible email address
The Commission will use the email address you provide on your registration application to communicate with you regarding your registration. You must provide an email address to which you have access in order to receive those communications.

Please check boxes to confirm that you have the following information/documents to register a minor patient in hospice care:

Caregiver ID Number
Your Caregiver ID Number was provided in your caregiver registration approval email. If you registered, but do not know your Caregiver ID Number, please contact MMCC. If you have not registered yet, please register. Please note that the caregiver must be a legal guardian of the minor patient.
The last four digits of the patient’s SSN
You must provide the last four digits of the patient’s SSN to register a patient.
An electronic, notarized copy of the Minor Patient Form
Please download the Minor Patient Form, complete the form, get it notarized, then scan or take a clear picture of the completed form.
An electronic copy of proof of guardianship for the minor patient
You must upload a copy of the minor patient’s birth certificate, adoption papers, or a court order awarding guardianship.
An electronic copy of the front and back of caregiver's government photo ID AND either
(1) proof of Maryland address or (2) name and address of the Maryland medical facility where patient is being treated.
The caregiver must upload a copy of his/her valid US government-issued photo ID, such as a driver's license, passport or military id.
An electronic copy of either a current photo of the patient OR a letter from the Attending of Hospice Record provider
A hospice patient must provide either a clear, color photo of the patient’s face taken within the last six months to reflect the patient’s current appearance or a letter from the attending hospice provider (Attending of Hospice Record or AOHR) on hospice letterhead stating that the patient is under his or her care.
If using a photo, it must be a clear, color photo of the patient’s unobscured face taken within the last six months to reflect the patient’s current appearance with a plain white or off-white background. The patient must be directly facing the camera and should have a neutral facial expression or natural smile with both eyes open. Generally, the photo should look like a driver’s license or passport photo. The file must be an image (.jpg, .png or .gif) no larger than 3 MB in size and may not be digitally enhanced or altered in a way that changes the patient’s appearance.
If submitting a letter, it must be from the Attending of Hospice Record provider on hospice letterhead stating that the patient is a hospice patient under his or her care. The file can be uploaded in .jpg or .pdf format.
Please refer to the Registration Instructions for more information concerning the photo and AOHR letter requirements.

If your photo does not meet our guidelines, your application will be returned.
An example of an acceptable photo is shown here.
A valid, accessible email address
The Commission will use the email address you provide on your registration application to communicate with you regarding your registration. You must provide an email address to which you have access in order to receive those communications.

Please check boxes to confirm that you have the following information/documents to register an adult patient:

An electronic copy of the front and back of your government photo ID AND either
(1) proof of Maryland address or (2) name and address of the Maryland medical facility where patient is being treated.
The patient must upload a copy of his/her valid US government-issued photo ID, such as a driver's license, passport or military id. If the government ID you are providing is not a Maryland driver’s license or MVA ID card, then you must also provide proof of a Maryland address or proof that you are in the State to receive medical treatment. If registering a minor patient who does not have a government photo ID, upload the caregiver’s ID. Please refer to the MMCC website for more information.
The last four digits of the patient’s SSN
You must provide the last four digits of the patient’s SSN to register a patient.
An electronic copy of a current photo of the patient
This must be a clear, color photo of the patient’s unobscured face taken within the last six months to reflect the patient’s current appearance with a plain white or off-white background. The patient must be directly facing the camera and should have a neutral facial expression or natural smile with both eyes open. Generally, the photo should look like a driver’s license or passport photo. The file must be an image (.jpg, .png or .gif) no larger than 3 MB in size and may not be digitally enhanced or altered in a way that changes the patient’s appearance. Please refer to the Registration Instructions for more information concerning the photo requirements.

If your photo does not meet our guidelines, your application will be returned.
An example of an acceptable photo is shown here.
A valid, accessible email address
The Commission will use the email address you provide on your registration application to communicate with you regarding your registration. You must provide an email address to which you have access in order to receive those communications.

Please check boxes to confirm that you have the following information/documents to register an adult patient in hospice care:

An electronic copy of the front and back of your government photo ID AND either
(1) proof of Maryland address or (2) name and address of the Maryland medical facility where patient is being treated.
The patient must upload a copy of his/her valid US government-issued photo ID, such as a driver's license, passport or military id. If the government ID you are providing is not a Maryland driver’s license or MVA ID card, then you must also provide proof of a Maryland address or proof that you are in the State to receive medical treatment. If registering a minor patient who does not have a government photo ID, upload the caregiver’s ID. Please refer to the MMCC website for more information.
The last four digits of the patient’s SSN
You must provide the last four digits of the patient’s SSN to register a patient.
An electronic copy of either a current photo of the patient OR a letter from the Attending of Hospice Record provider
A hospice patient must provide either a clear, color photo of the patient’s face taken within the last six months to reflect the patient’s current appearance or a letter from the attending hospice provider (Attending of Hospice Record or AOHR) on hospice letterhead stating that the patient is under his or her care.
If using a photo, it must be a clear, color photo of the patient’s unobscured face taken within the last six months to reflect the patient’s current appearance with a plain white or off-white background. The patient must be directly facing the camera and should have a neutral facial expression or natural smile with both eyes open. Generally, the photo should look like a driver’s license or passport photo. The file must be an image (.jpg, .png or .gif) no larger than 3 MB in size and may not be digitally enhanced or altered in a way that changes the patient’s appearance.
If submitting a letter, it must be from the Attending of Hospice Record provider on hospice letterhead stating that the patient is a hospice patient under his or her care. The file can be uploaded in .jpg or .pdf format.
Please refer to the Registration Instructions for more information concerning the photo and AOHR letter requirements.

If your photo does not meet our guidelines, your application will be returned.
An example of an acceptable photo is shown here.
A valid, accessible email address
The Commission will use the email address you provide on your registration application to communicate with you regarding your registration. You must provide an email address to which you have access in order to receive those communications.

Please check boxes to confirm that you have the following information/documents to register as a caregiver:

An electronic copy of the front and back of your government photo ID AND either (1) proof of Maryland address or (2) name and address of the Maryland medical facility where patient is being treated. (You must be at least 21 years old to register as a caregiver.)
The caregiver must upload a copy of his/her valid US government-issued photo ID, such as a driver's license, passport or military id. If the government ID you are providing is not a Maryland driver’s license or MVA ID card, then you must also provide proof of a Maryland address or proof that your patient is in the State to receive medical treatment. Please refer to the MMCC website for more information.
The last four digits of the caregiver’s SSN
You must provide the last four digits of your SSN to register as a caregiver.
An electronic copy of your current photo
This must be a clear, color photo of the caregiver’s unobscured face taken within the last six months to reflect the caregiver’s current appearance with a plain white or off-white background. The caregiver must be directly facing the camera and should have a neutral facial expression or natural smile with both eyes open. Generally, the photo should look like a driver’s license or passport photo. The file must be an image (.jpg, .png or .gif) no larger than 3 MB in size and may not be digitally enhanced or altered in a way that changes the caregiver’s appearance. Please refer to the Registration Instructions for more information concerning the photo requirements.

If your photo does not meet our guidelines, your application will be returned.
An example of an acceptable photo is shown here.
A valid, accessible email address
The Commission will use the email address you provide on your registration application to communicate with you regarding your registration. You must provide an email address to which you have access in order to receive those communications.

* Indicates required field

* Create a Username

* Create a Password

* Confirm Password

* Email

* Confirm Email

* First Name

Middle Name

* Last Name

Suffix

* Last 4 Digits of SSN

* Date of Birth

* Gender

Male Female

* Race

* Are you a hospice patient?

Yes No

I am not a Maryland resident. I am present in the state for the purpose of receiving medical care from a Maryland medical facility.

Maryland Address

* Name of Maryland Medical Treatment Facility

* Address 1

Address 2

* City

* County

State

Maryland

* Zip Code

Non-Maryland Address

* Address 1

Address 2

* City

* State

* Zip Code

* Phone #

* Government-Issued Photo ID (front)

Government-Issued Photo ID (back)
(Required for driver’s license/MVA Cards only)

Proof of Address
(Required if current address is not printed on
Government-Issued Photo ID)

* Recent Photo

To resize, rotate or crop your photo, use the Photo Tool

PLEASE NOTE:

If you live in Maryland and your government ID does not identify your current Maryland address, you must upload one photo that includes two acceptable documents that show your Maryland address.
Please align the documents in the photo so that your name and address, as well as the sender/type and date of the document are clearly identifiable. Acceptable documents include utility bills, bank statements, and mortgage statements. All documents must be dated within the past 90 days.

AOHR Letter

* Official Proof of Guardianship for Minor

* Notarized Minor Patient Form

* Caregiver ID Number

* Is the patient an active duty law enforcement officer, correctional officer, probation officer, paramedic or firefighter?

Yes No

* Does the patient have a school bus permit or a Commercial Driver’s License?

Yes No

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NOTE: ACCESS TO THIS SYSTEM IS RESTRICTED TO AUTHORIZED USERS ONLY AND LIMITED TO APPROVED BUSINESS PURPOSES. BY USING THIS SYSTEM, YOU EXPRESSLY CONSENT TO THE MONITORING OF ALL ACTIVITIES. ANY UNAUTHORIZED ACCESS OR USE OF THIS SYSTEM IS PROHIBITED AND COULD BE SUBJECT TO CRIMINAL AND CIVIL PENALTIES. ALL TRANSACTIONAL RECORDS, REPORTS, EMAILS, SOFTWARE, AND OTHER DATA GENERATED OR RESIDING UPON THIS SYSTEM ARE THE PROPERTY OF THE STATE OF MARYLAND.

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