DOC request three complete - Cannabis Defense Coalition

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.. A i ug.13. 2008 12:35PM
./ .
Sc'ott L. Havsy, DO, DAAPM
'\ 7,J)
".."ot~ . .'
f~ STATE OF WASHINGTON
• ........,. DEPARTMENT O~ CORRECTIONS
Medicinal Use of MarijuanaVerification
OF'FENDER I.D. DATA;
No. 5731 P. 1
Dear Prescriber, .
By state statute the Washington State Department of.CorrectiQns is charged with the responsibility to supervise some
offenders after they ~ave been convicted ora felony. The above named patient is currently unde~ supervision by the
Department. S'upervision is designed tei help the offender avoid those environments or situations that lead to their criminal
behavior. Often illicit drug use is a contributing factor in an individual's criminality. Accordingly it's usual that the.court or
the Department of Corrections will impose a condition of supervision ·that the offender not use, or possess illicit drugs,
including marijuana, This offender has claimed that they have a condition for which the medicinal use of marijuana has
been prescribed:The below verification is to determine the legitimacy of their claim. Thank you in adva,nce for your .
assistance, If you have questions please feel free to personallycontaci the Medical Director of tbe Department at (360)
725-8700.' . . . .
1. I.s this patient unQer y.our care ~ DNo
2. Ale you prescribing medical marijuaha for his, patient due to a diagnosis of Acquired-
Immunodeficiency Syndrome (AIDS)' .
3.
a. If the answer te question 2 is ·Yes·, does he/she ha,ve anorexia
b. If the answer to question 2a is ·Yes H , d,oes he/she have weight"loss .
Are you prescribirig medical marijuana for' this patient.due to nausea and vomiting Clssociat!'!c
. wit~ cancer chemotherapy
"
a. If the answer te question 315 "Yes', has the patient faileqto respond. to canventional
a:ntiemetic treatments'. . .
DYes
DYes
·DYes
0 Yes
DYes
. b. If the answer to question 3a is "Yes·, please describe what these treatments were (medication, dbse,
dura~on): . .
--rrNo
DNo
DNa
c. What isthe planned schedule of chemotherapy
4, V"hUe on community supervision ("parole") the Department' of Correctiens only authorizes the
use of the oral synthetic formulation of marijuana. If the Deprtment authorizes this pati~nt's 0 Yes -EtrTo
use .of medical marijuana, will you be prescribing .only the .oral synthetiC formulaticn
5: . The patient's accompanying Release of hiformation' autharizes yeu ta previde the' ;J, ~.
Department with current a"nd future inforr:nation related to this issue. Do yell agree te notify OY~ _. 0 No.
the Department's Medic1 Director .of any changes in you;:,r~. ~w::.:e::!.ts~ab~O~V~e~ _______ ----,;-(t.!...-___ --,-___ _
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Prescriber's Address it],
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