DOC request three complete - Cannabis Defense Coalition

MAR/18/200S/WED 03:05 PM
FAX No,
MAR 252009
Dept of Cprrectioras
Health Servic~s
To be flJI~ out by Prescriber:,
Pear Prescriber, ' ,
By state statute the Washington State Department of-Corrections is charged with the responsibility to supervise some
offenders after they have been 'convicted of a felony. The above named patlent Is currently under supervision by '!he
Department Supervision Is designed to help the offender avoid thOS& environments or situations that lead to their qriminaJ
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 drugll,
Including marijuana Thls 6ffen~er has claimed that they have acOndll1on for Which the mediansl use of marijuana has
bean recommended. The below verification is 10 determine the legitimacy of their claim. T.!'Jank you In edvaFlc8 for your
3sslstanee. If you have questions please feel ITeS to per-lonally contact th~ Medlcal Director ofthe DepartmeDt at (360) ,
725-8700. '
1. [s thls,patlent under your care
2. Are you recommending medical mariJu~na for hIs patient dUe to a diagnosis of Acquired
[mmu!lodeflclency Syndrome (AIDS)
a. If the answarto question 215 "(es·, does he/she have anorexia
b. If the answer til question 2!i is "Yes",does he/she ha~e weight JO$$
3. Are' you recommending medical marijuana {or this patient due to nausea i!lnd v~miting
associated with cancer chemothQrapy
B'Y'es
DY~
'DYes
DYes
DYes
ONo
DNo,
a. If the answer to question 3 Is "Yes", hasl:he patient failed 10 respond to conventionel 0' Yes 0 No
~ntlemetle t.-eatments
b. If the answer to questlon,3a is "YI;lS·, please describe what thoss lreatments were (medi~t1on, dose,
duration):
c. What js the pl:;Jnned schedUle of chemotherapy
4. If you answered °No" to items 2 & a above, what Is th~ raason you are n~commendIng medfcinaf use of
marijuana!' , \, ' ,
C. ~'fc.{\,k.. ~iY\,
CiI.
Please provide evidenc~ published in a peer-reviewed scientIfic publ!eatlon to support the medicinal ).lse of
manjuana for thIs purpose, '"
,5. While on community supervision ('parole' thlil Department of Corr,eotitll)s 'only authorIZes the '
use of the ora! synthetre formulation of marlj~aoa,~!fjbe_Dapar.tr.net:lt..autl:ior.lzBs-tf:1is-patieflt's-El-y.$S---~0
'--u"',s""e""'or meoicaJ marijuana, Will you be prescribing only the oralsynthettcfcrmulation .
S. The patienfs accompanying Release of Information authorizes you to provlde'the
Department with ourrent and future irn9rmation related to thIs issue. Do you agree to notify
the Department's Medical Oireotor of any ohanges in your answers aoove
DYes
~o,
ooc 14-01)3 (Rev. 7I31106j
OOC3B0..200
PDU-6655-3 000220