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Prescriber's Name (Print) Presorl~r's SIgnature 3-:'1-01 Date License #: License type: , ' '\3,\/:\", $~(et..~; '~Jt1.@v" • c{.!; It e yytCHI\P\.;j(.JY' Prescriber's Address J Phone Number Prescriber: please return this form and the pat/ent's Release of Information to: Medical DireCtor Health Services Division Washington State Department of Corrections PO Box 41123 Olympia, WA Q8504-2113 To be, filled out by DOC' Physician: I have reviewed this verification form and find that use of macncal marijuana by this patient , (check one)' lOis 0 is not ' , . consistent with DOC Polley. Physicia,n's Name (Prlnt) Physlclan's Signature Date ,lnstr-uctiq,gEl.to,oqc Ph~sicl~: When form Is complete: 1. Email your finding above to the Assistant ,Secretary for Cominun'lly 90rrections 2. File this form and ~e accompanyihg Release of Information, In Uberty as a Community Corr~ctlons Health Record. ' State law (RCW 70.02; RCW 70.24.105; RCW 71.05.390) andfor fedaral regulatfons (42 CFR Part 2; 45 CFR Part 164) prohibit disclosure ofthls Information without the specific written consent of the person to whom It pertaIns, or as othernlse . permitted by law. DOC 14-053 (Rev. 7/31/08) DOC 380.200 PDU-6655-3000011
STATE OF WASHINGTON DEPARTMENT OF CORRECTIONS P.o. Box 411 00 • Olympia, Washington 98504·11 Oil March26,2009 ,Bremerton, WA 98310 DearMl: •• , Your Medicinal ,Use of Marijuana request Was received on March 18 i 2009. Uponrevlew by the, Deparlment of Corrections' Health. Services physician, your request has been denied. You may appeal this decision by s~ding your written request within 15 business days, on or before Apri117.2009. Please send your .request to the address below: ' Karen Daniels, Assistant Secretary Community Con-eclions Division Department of Corrections P.O. Box. 41126 Olympia, WA 98504·1126 , ' Your request must provide additional information that wa~ not included with your original request. Appeals that do not contain new information will be denied. You 'Will receive a response to your appeal requeSt witlrin30 days of receipt. Karen Daniels, Assistant Secretaly , Community Corrections Division KD:md , 00: Miabael Isoo, Community Corrections Supelvisor Lee Cecil, Community Cor.i:ections Officer , . 'Field File -_ . . , II Working Together for SAFE CommunftleS" PDU-6655-3000012
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Page 3 and 4: RECORDS PROVIDED WITH REDACTIONS ~~
Page 5 and 6: (".- " ~"""'":.~ Inr ... ~ STATEOFW
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Page 13: ... ""'"'''' f~ STATEOFWA$HINGTON ~
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Page 21 and 22: Fax : ' 3115,E. Mission Ave Spokane
Page 23 and 24: Or-FENDER 1.0. DATA, j' STATE OF WA
Page 25 and 26: DoCumentation of Medical AuthoriZat
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Page 33 and 34: 311S'E. Mission Ave Spokane, WA 992
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Page 37 and 38: j I Documentation of MedicarAuthcir
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Page 41 and 42: Chapter 69.51 A RCW: Medical marij1
Page 43 and 44: Chapter 69.S1A RCW: Medical marijua
Page 45 and 46: Chapter 69.511). RCW: Medical111ari
Page 47 and 48: •• I ! 3115 E. Mission Ave Spok
Page 49 and 50: OFFENDER 1.0. DATA: STATE OF WASHIN
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Page 55 and 56: Prescriber's Name (Print) License#:
Page 57 and 58: 3115 E. Mission Ave Spokane, WA 992
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Interpretation of Medical Marijuana
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to be processed now. If this was re
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I J i Date License type: Prescriber
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Distefano, Monica J: (DOC) From: Se
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STATE OF WASHINGTON DEPARTMENT OF C
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February 17, 2009 STATE OF WASHINGT
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DOC request three complete - Cannabis Defense Coalition

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