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- /ttors.u, . OFFENOERLD. DATA: ----- ~ -g ~"[J£' ."\ STATE OF WASHINGTON. l> • DEPARTMENT OF CORREC,.'ONS AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION I, hereby authorize the use or disclosure of my health information as described below. The following ir:divldual or organization is authorized to make the discl;sure: NAME: ADDRESS: Dr. Antoine Johnson/CBR Medical, Inc, 31151=. Mission Ave. Spokane, WA. 99202 i. The type and date(s) of information to be used or disclosed is as follows: All medical history, and other information used to screen offender for Medical Marijuana consideration. Purpose for disclosure: Provide DOC with current and future' information related to offender's health status. I understand that the information in. my health record may include information relating to sexually transmitted infection.s, Acquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV). It may also include information about behavioral. or mental health services arid treatmentfor alcohol and drug abuse. This information may be disclosed to and used by the following individual or organization: Dr. 'Steve Hammond, Medical Director . NAME: Washington ·State Dept. of Corrections ADDRESS: 7345 Linderson Way SW. Tumwater, WA. 98501 ·1 understand that I have a right to revoke this authorization at any time. I 'understand that if I revoke this . authorization I must do so in writing and present my written revocation to the Health Information Management Department. I understand that the revocation will not apply to information that has already been released in response to this authorization. Unless otherwise revoked, this authorization will expire on the following date, event, or condition: 1/1/2010 (if left blank, authorization will expire six (6) months from signing). I unc;lerstand that authorizing the disClosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524 and RCW 70.02. I understand that any disclosure' of information carries with it the potential for an unauthorized redisclosure and may not be protected by fegeraJ or' state confidentiaiity rules. If I have qUI~')tions about disclosure of my health information, I may contact the RHIT/designee of the facility: ..' ~--~------------------------~------------- Date (Qo_DQ.l~n ifform is not comRlI1~) ___•__(Patient to comQleteL..l _____ ---~ Social Sequrlty Number' te of Birth DOC Number L2Li7~'_ Wjof' . ~9t:f'0fWi . ate Siale law (RCf!' 70.02; RCW 70.24.105,: ReW 71.05.390) andlorjederal regulalions (4'2 CFR Part 2; 45 CFR Pari 164) prohibil disclosw'e . oJthis inJormation withoullhe specific wrillen consen( oJllze persoit 10 whom it perlains. Or as otherwise permitled by law. DOC 13·035 (05/19/2008) POL . DOC 380.200 DOC 600.020 DOC 640.020 DOC 670.020' LEGAL PDU-6655-3 000169
STATE OF WASHINGTON DEPARTMENT OF CORRECTIONS P.O. Box 41126' Olympia. W:lshingloll 98504-1126. FACSIMILE TRANSMITTAL SHEET TO: Melissa Leggee COtv!PANY: FAX NUMBER: 509-340-2710 PHONE NUMBER: FROM: Monica Distefano DATE: NOVEMBER 19, 2008 TOTAL NO. OFPAGES INCLUDING COVER: 6 SENDER'S PHONE NUMBER: 360-725-8796 SENDER'S FAX NUMBER: 360.;586-0252 o URGENT X FOR REVIEW o PLEASE COMMENT 0 PLEASE REPLY 0 PLEASE RECYCLE NOTES/COMMENTS: Please let me know if you need'anything else, M~lissa. Monica Distefano Executive Secretary 360-725-8796 . PDU-6655-3 000170
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STATE OF WASHINGTON DEPARTMENT OF C
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RECORDS PROVIDED WITH REDACTIONS ~~
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(".- " ~"""'":.~ Inr ... ~ STATEOFW
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i ( Documentation of Physician Auth
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OCT/ Oct. B. LUO~, 11: ::J9AM T ~co
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... ""'"'''' f~ STATEOFWA$HINGTON ~
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Distefano, Monica J. (DOC) From: Se
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eRR Medical, Il1c 3115 E. Mission A
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Fax : ' 3115,E. Mission Ave Spokane
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Or-FENDER 1.0. DATA, j' STATE OF WA
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DoCumentation of Medical AuthoriZat
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STATE OF WASHINGTON DEPA'RTMENTOF C
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311S'E. Mission Ave Spokane, WA 992
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j I Documentation of MedicarAuthcir
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Chapter 69.51 A RCW: Medical marij1
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Chapter 69.S1A RCW: Medical marijua
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Chapter 69.511). RCW: Medical111ari
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•• I ! 3115 E. Mission Ave Spok
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OFFENDER 1.0. DATA: STATE OF WASHIN
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Prescriber's Name (Print) License#:
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3115 E. Mission Ave Spokane, WA 992
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. ! STATE OF WASHINGTON DEPARTMENT
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STATE OF WASHINGTON .DEPARTMENT OF
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T.)' ~x.. MARIJUANA MEDICINE'· 'EV
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No'v, 26, 2008 4:48PM CB R Me d i c
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.~. :.' '. ATTEN1':tON LAW ENFORCEM
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\"'Ior"'.~ OFFENDER 1.0. DATA: I f
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Wheeler, Judine L. (DOC) From: Sent
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OMNI: Chrollos Quick Search , •
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-...... THCF MEDICAL CLINICS 1813 1
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Prescdbar's Name (pnnt) . Prasc~jje
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I I do ncit want to ruffle feathers
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Let me know if you have questions f
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Interpretation of Medical Marijuana
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From: Sent: To: Duggan, Brenda J. (
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NIELSEN TO COME UPSTAIRS. CCO NIELS
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Date & Tirpe Created: 12/16/2008 11
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PRIMARY CARE PHYSICIAN AND LOOKED O
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Distefano, Monica J; (DOC) From: Se
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3. High Non-Violent 4. Moderate, an
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, ' ~. With Community Corrections S
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I FW: 380200 Community Supervision
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FW: 380200 COInmunity Supervision o
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Distefano, Monica J. (DOC) · From:
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Distefano, Moriica J. (DOC) From: .
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j I Distefano, Monica J. (DOC) From
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Page 153 and 154: Distefano. Monica J. (DOC) From: Se
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Page 157 and 158: I:--- j ! -_. Distefano, MonicaJ. (
Page 159 and 160: Dec .. l0. 2008 1:34PM CBR Medical
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Page 163 and 164: Distefano, Monica J. (DOC) From: Se
Page 165 and 166: Stern, Marc F. 'Dir Hlth Svc' (~OC)
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Page 169 and 170: I J i Date License type: Prescriber
Page 171: Distefano, Monica J: (DOC) From: Se
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Page 177 and 178: STATE OF WASHINGTON . DEPARTMENT OF
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Page 189 and 190: .Distefano, Monica J. (DOC) From: S
Page 191 and 192: ~ec. 23. 2UUB 9:U,PM' (;~K Medj'cal
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Page 195 and 196: STATE OF WASHINGTON DEPARTMENT OF C
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Page 209 and 210: 04/15/2009 18:28 4258696378 THCF PA
Page 213 and 214: Fax 36027706511· Apr 20 2009 04;31
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. I, Offender Name STATE OF WASHING
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PDU-6655-3 000236
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clan, 23, 2009 11: SOAM CBR Me~ical
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,_. ! j 1 Distefano, Monica J. (DOC
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STATEOFWASHINGTON . DEPARTMENT OF C
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Documentation of Medical Authorizat
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---_._.-» " Distefano, Monica J. (
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Prescriber's Name (Print) License #
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OFFENDER I.D. DATA: STATE OFWASHING
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1813 Born Avenue NE, Suite'#210 Bel
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i I Documentation of Medical Author
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Distefano. Monica J. (DOC) From: Se
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;lan.14. 2009 9:52PM CBR Medical In
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Jan, 14, 2009 9:53PM CBR Medical In
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Ja n,. 14,2009 9:54PM CBR Med i ca
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3115 E. Mission Ave Spokcme, WA 992
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OFFENDGR I,D, DATA: STATE OF WASHIN
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.IL , Documentation of Medical Auth
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J STATE OF WASHINGTON DEPARTMENT OF
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3115 E. Mission Ave 'Spokane, WA 99
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OFFENDER 1.0. OA·I.o.: STATE OF WA
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MARIJUANA MEDICINE- EVAlUATtON CENT
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~flor~1I .J''; ~. I l ~ATE OF WASHI
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'I ! I i Prescriber's N~rint) , Lic
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· I, Karen Hamilton, am a physiCia
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Distefano, Monica J. (DOC) From: Ha
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OFFENDER 1.0. DATA: STATE OF WASHIN
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Page 3 of3 To: Checo, Ana V. (DOC),
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PageZ of3 . 253-372-6463 office 253
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Jan. ::lU. :.1UU9 1 L: U~PM ~cott L
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OFFENDER 1.0. DATA: STATE OFWASHING
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Scott L. Havsy, DO, DAApM -Board Ce
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I Prescriber's Name (Print) License
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Living &: WeUness Centerss P.S. 371
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FEB-18-2009 14:56 From: To: 360 586
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M •••• M •• __ • ___
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STAT!: OF WASHING"ON DEPART1\lIENT
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Dec. 12. 200 8 4 : 03 PM C B R Md i
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Dec. 12. 2008 4:04PM I CBR Medical
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. Nov. 2~. 2008 3: 05PM CBR Medical
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"NOV-12-2008 WED 01~45 PM SPOKANE'N
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Dec.23. 2008 ,:31PM GSg Medical Inc
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Dec, 23, 2008 5: 32PM CBR Med i ca
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CO (') -K~ . C c..l)' ,_ .,..,. ADD
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Dec.23. 2008 4:41PM CBR Medical Inc
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Dec.23. 2008 4: 42PM CBR M~dical In
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D.ec.23. 2008 4:43PM CBR Medical In
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Dec.23. 2008 4: 49PM C B'R ·M.e di
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Dec, 23, 2008 4: 50PM CBR Medical I
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I I , Smith, Sherri K. (DOC) From:
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~- 6S/2e/26ee 12:ae 2538475797 PAGE
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February 17, 2009 STATE OF WASHINGT
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Jan. 4. 200912:40PM CBR Medical Inc
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Jan, 4, 2009 12:41PM CBR Medical In
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Dec.30. 2008 12:20PM CBR Medical In
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Jan. 4. 2009 12:40PM CBR Medical In
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Documentation of Medical Authorizat
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