DOC request three complete - Cannabis Defense Coalition

OCTiLVu~t'VVtlO/liL~,U~4I, ~hj~~ Ta~p-S ~. 'Havsy, [}V, lIA~rl~AX No. i253597r'l
NO, ILlll r, j
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license type:.
.~oate
Prescriber's Address
. 'Pho!'16 Number.
. prescrIber. please returnt~l. form ,and the patient's Release af Informat!0n to:
Medical Olrector
Health Servloes Division'
Washington State Department of CorrectionS
PO BoX 41123
Olympia, WA eSS04-2113
To be fined out by DOC Phy.slclan:
"
I Iiave reviewed U,is, verification 'form $nc! find that' use of medical marijUana by this ,patient
" (check Dne) lOis CJ I. not " ....'
consj~ht \¥ith DOC Policy. " .
jShYCldanl~ NIU1I11 (l'rtnt) .
P"yslclan's Slgnscure
InstNc~ions to DOC ~hysician:
When form Is complete: . ,
1.' ErnaR yourtindi!1g above ~ the Assistant seCretary for Community Corrections
2. ,File this forrn iJnd the acccmpan~~g ~lease of Jnform~tio.n in LiJj~ as a Community Co~ons Health Record.
"
'.
. Slate law (RCW 70.02; RCW 1Q.24.10$; RCW 11.05.390) andfDr Mder.ll regulatiDIIS (42. CFR Pllrt 2; 4S CPR Part 164) pf"CIhibit
. . disdDSU~ oftIJis infonnan wf\hout the speclft~ wrfHan consent of ilia parsDft 10 wIIcrn ft ptrtalnl, or as atherwlsa
pennltted bylaw. .
COC 14-05:3 (Rev. 7/31/08)
DocaeO,20a
PDU~6655-3 000007