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11/06/2008 13:06 ·111111111111 PAGE 05/08 " h Prescriber's Name (Print) Prescriber's Slgna!;ure -Oate Ucense#: License type; prescriber's Address v-rA I" 6 .., ~ _ p ~.,.r-; c:·."...,.....J ,-/0"3 Phone. Number (ji .f" J) e s ~ - "2....6 6 6 prescriber; please return .thls form and the patient's Release of Infonnation t~: Medical Director Health Services Division Washington State Department of Corrections PO Box 41123 Ol~pia; WA 98504-2113 Physician's Name (Print) Instructions to DOC Physician: Physicilan's SignabJre Data When form is complete: 1. Email your finding above to the Assistant Secretary for Community Corrections . . 2. File this form and the accompanying Release pf Information in Uberty as a Community Corrections Health Record. PCP._._ .._.______.___ lnilials-_ .. Mil., ....:___.••___.______...________ Ii1iri1-lls_· -. . RC _.__________.•.__..-c-_Initlells._.._ -----·-----·------·-·-----·-·--·---·-pcc.~__.._:-.--...._._..._,.....__ !nitial~l._.__ Enc# •._____ .•.-"'-------. PCP'. ____"__.~~._..... ~_ ..._.._·_·_·_~..'"·~·__· S('j~n (J..at{:=:~..__....... ~_ ..._......_~~........__,'"'.,..."'.. l nfiif.I.!~1 ,.:-....._ .. ~ . Doc Type. ____. __...;.--~------ Stat" law. (RCW 71)
I:--- j ! -_. Distefano, MonicaJ. (DOC) From: Sent: To: Subject: Distefano, Monica J. (DOC) Tuesday, December 23,200812:16 PM Fix,~ertA. (DOC) -F~mm request· FYI Monica Distefano Executive Secretary to Karen Daniels, Assistant Secretary Community Corrections Division 7345_ Linderson Way SW Tumwater, WA 98501 MS: 41126 (360) 725-8796 mjdistefano@d9c1.wa.gov From: Sent: To: Cc: Subject: Hammond, G. Steven (DOC) Friday, December 19, 2008 9:55 AM _ Daniels, Karen R. Distefano, Monica J. (DOC) request Md ••• II::ase does not meet DOC criteria for approval of medical marijuana. G. Steven Hammond PhD, MD, MHA Chief Medical Officer Health Services Division Department of Corrections. POS41123 _ TUIDwater, WA 98504-1123 - 360-725-8700 - ! 1 PDU-6655-3 000154
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STATE OF WASHINGTON DEPARTMENT OF C
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i ( Documentation of Physician Auth
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Wheeler, Judine L. (DOC) From: Sent
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Interpretation of Medical Marijuana
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Date & Tirpe Created: 12/16/2008 11
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Documentation of Medical Authorizat
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