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04/15/2009 18:28 ~258696378 THCF PAGE 04/~4 . Prescriber's Name (Print) Cate b " . I t r W\Co'\"''i ~ .. License#:,{'i'V'.. . S< li\C~\~:'rY( 0-1~t'L~ LlcEi.nsetype:. _. ____________ ""-__ 'Prescriber's Address . ...l'S 15'1') 1'"36;'-" ~(.. IVt. ~ 2.ll> '.' Pho~e ~umber .eI.\e....."\~ twA- ·&\govS.. . ·Presc.rlber: please return 'this 'f~rm ant! the patient's Release:of Information to: ~edical Director . .' Health Services DivisiQn Washington State Department of Corrections . . ' . . PO BoxA1'123 . . Olympia, WA 98504-2113 To' bEiill,ed out by .DOC 'PhY8ician: I have fevie~ed this ve~~cati~n'~~ }I'lc(find that use. ~f medicar ma~j~ana by this. patient '. ".'1.. '(¢hecl< one) lOis 'lkd'1s oot'. lit,.· .' consistent with DOC Policy. '. '. J! 11_. . . Physiclarr.s·Name (Print) ~~ Physician's Signature .' Oate Instr.uctlons·to D.OC P~ysician: When form. is ~cniplete: . . . 1. Email your finding above to the Assistant Secretary for .community Corrections. . . . 2. 'File'this:fo~m and the acco.!'TlpanYing·Releas~ of I~fonnaticin in.Lib~rty as a Community Corrections Health Record. 'State law (Rc:W70.D2i RCN 70.24.105; RCWj1.05:390) and/or federal regulatit;ms (42 Ci'R. Part 2j 45 CF.R Part"164) .prohlblt 'disclosure ofthls infonnirtion wit~out·th9 specific written conss\'It of the person to whom It per1alns, or. as otherwise. pormllt=d by law. . . . DOC 14-05~ .(Rev. 3/16f09) DOC 380.200 '. PDU-6655-3 000205
04/15/2009 18:28 4258696378 THCF PAGE 01/04 Fax Cover Sheet THCF Medical Clinic Thomas Orvald, M.D. 1813 130 fu Avenue NE, Suite 210 Bellevue~ WA 98005, Phone: (425) 869-6186 Fax: (425) 869-6378 I I , ! 'From: () {' t--- Attention:, --~--~-------- Phone: _____________ ~ Phone: ________ __ Fax: _~_.......:..---___:_-.....o.--- Pages:' "S '+ (oj-v" ~e: SI' 'l ' i \- l../",,") P (e~s~ c.C-il\ 'I~ ~ " . . Notes: ~ .~ '- PDU-6655-3 000206
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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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'.!, To: C!6R MedicaO,. h'IlC 31)5
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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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''' .. r.~ l~} STATEOFWASHINGTON "1
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j I Documentation of MedicarAuthcir
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, • J ' -1. d; z.. 00 g-' /Vo v.
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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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.,.,... ..,..,.~ f~J STATE OF WASHI
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Nov. 26. 2008 4:37PM CBR Medical In
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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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E.... KIOSK reporting may be used i
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RE: 380 200 Community Supervision o
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RE: 380200 Community Supervision of
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to be processed now. If this was re
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FW: 380200 Community Supervision of
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FW: 380200 Community Sup_ervision o
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OFFENDER I.D. DATA: STATE OFWASHING
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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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J STATE OF WASHINGTON DEPARTMENT OF
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3115 E. Mission Ave 'Spokane, WA 99
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MARIJUANA MEDICINE- EVAlUATtON CENT
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