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FAX No. 509-921-2346 P. 003 r-.... (~ STAT&:OFWASHINGTON DEPARTMENT OF CORREC110NS I.JU!,# Medicinal USQ of Marijuana Verification. To befiJled out by ceo: I Patient'~ Name _L-... OFFSIIIl51l.1.D. QhT", __--:-__--,-_--J_==:..1_ 8 9_ l o/'_5 ____ I ,...-LI__ er ___... I· To bllfmed out by Prescriber: I . Dear Prescriber. By state statute the Washington Slate Department of CorrectIons r~ charged wlth the responslbiiity· to supervise some offenderS after they have been convicted of a felony. The above named patient is currently undl'lr supervision by the Department. SupervIsion is designed to.help the affender avoId lhQIOe environments or slttJatio!'l$ that lead to their criminal behavior. Often illicit drug use Is !i contrlbutingfacto( in an indivldua.l·s criminality .. Accordingly Itls usual that the court or the Department of Corrections will impose 8 condmon of supervision that the offender not use, or possess ilficit drugs, Including marijuana. This affencjer has claimed ~hat they have a condition for which' the medicinal usa of marijuana has been recommended. The belollv verification Is to determine !he legitimacy of their claim. Thank you In advance for your· assistance. Jf you have questions, please contact the CommunIty Corrections Aasistan~.Secr.etary at (360) 7'2.5-4!.787. 1. II'! thIs patient under your c~re7 Q'Yes 0 No 2. Are you recommending medical marijuana for this patienl due to s dlagnosfs of Acquired Immunodeficiency Syndrome (AIDS) a. If the answer to question 218 "Yes','does he/she have anorexia, b. . If the answer to questIon 2a is ·Yas", does ~e/she have weight Joss' DYes DYes DVes ~o DNa ONo a. Are you reoommending medical marijuana for Ihls paDent due to nausea and vomitlng . assoeiated WIth cancer. chemotherapy a. Jf the answer to quesfion 3 is "Yes', has the patient failed to respond to conventlol'lSl entlemofic ireatml)nts DYes DYes b. If the answer to que3tJon Sa is "Yes", please ctesetibe whISt those treatments were (medication. dose, du~tion): .. .. . . . 0No' ONo c; Wh
., FAX No. 509-921-2346 P.' 004 Pr~criber's Address Phone Number Prescriber: please return thl~ fom and the patient'e Release of Information to: Medical Drreator Health Servioss Division Washington StaTe Departmeniof Correctlone ceis9x·411W Olympia, WA9B604-2113 pnyolclcm's Nema (F'rtnt) Physr;ran's Slgnawre Instrllctions to <strong>DOC</strong> PhysiCian: When form is colnplete: i. Email your finding above to the Assistant Secretary tor Community Correct/ons. 2. FJls this form and tha accompanying Release of Information in Liberty as a Community Correctlcns Health Record. 8~e f~ (RCIiIJ 70.Q2; RCW1Q.24.'05i RC'/{T1.0S.S90) ancllor fedenl T"9ulatlohSl (42 CFR Part 2; 4S CPR PISrt 164) prohibit .diIiClOl5un: oftms InfcmnatJon withom the spegilic wrjtf;en consent of rna Jl&Tson to whOfll It partalns, or as othe('Wlso PQnnltted by taw. <strong>DOC</strong> 14-053 (Rev.3i16{09) OOC3BO,200 PDU-6655-3 000196
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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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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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Wheeler, Judine L. (DOC) From: Sent
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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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I FW: 380200 Community Supervision
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3115 E. Mission Ave Spokcme, WA 992
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OFFENDER 1.0. DATA: STATE OF WASHIN
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OFFENDER 1.0. DATA: STATE OFWASHING
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