DOC request three complete - Cannabis Defense Coalition

~ec. 23. 2UUB 9:U,PM' (;~K Medj'cal lnc. No. 2829 P. 2133
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(~ STATE OflWASHINGTON
. ~ DEPARTMENT 01' CORREC1'lOI\l$
AUTHORIZATION FOR DISCLOSURE
hereby authorize the· use or disclosure of my health Information
as described below. The following individual or organization Is authorized to malce the disclosure; .
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ADDRESs.: .'-2' I I "":r t"-- , A/Ir' 50 -:;" cJ ' .
ADDRESS:;Y' ~r ~jZ;eX 'ft5jtJ Y1
! understand that I have a right to revoke this authorization at any time. I understand that if I revoke this .
authorization! must do so in writing and present my written revoGation to the Health Information M