DOC request three complete - Cannabis Defense Coalition

No,7218 pP, 3
, UUj
C81'\SS #:
license type;
kQoate
prescr/bar:' pleass return thll torm.sod the' patienfs Release, of InfCllTlla~n to:
Mel/loal Dlreetu!'
Health Servloas Divl$ion
W;;eh!nGtQn S1Ble Department of Corrections
PO!3ox41123
OIY':'Pia, WA 08504-21H! .
To be fined out by DOC phY.slcfan:
1 have revfeWlKi 1111& verification 'form and"flnd !hat Use of medical marijuana by this' patient
, (ohsO!: or.e) I Llle 0-11 not " " " .
00 "~with DOC Fa/loy. v
lnatructiuns to DOC ~hpjciam
When fllnn Is complete: " .
1. email yourfindlngabovetotheA.lllItantse«etar.l.ror CommunitY Carrections
2. FDe th,is funn and the accompanylng ~ease of lnform~tion in Liba,"t't as a Commlll1lty COrrectlomr Heafil1·Reeertl:
"
Slate law (RCW 70.02; RCW 70..2ol.1Od; Fl.eN 11.O~.~1 JIndf.r fiodan!l r'egulall .... (~2 01'1'1 PlII'I 2: 41 ePR Part 1114) pRltJibit
lIisclasllre Qftfli& infimna6o!T wil/tQ\lt the speclli" wntten callSlnl of th8 psrSMIIo vdtom It paJUlnI, of";' ethllrwl1f.
ponnl1ld byt.;w.
COO 1~05S (R81I. 7131108)
DOC