DOC request three complete - Cannabis Defense Coalition

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prescriber's Name ,(print) ,.-j 7
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ff' .3 Prescriber's Signature I
License #: (Y\.. D 000 25 License type:-
Date
Prescriber's Address 3 0 f s-. "3 d- 0-1'4' '. Phone Number
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Prescriber: please return this form and the patient's P~ease of Information to: .
Medical Director
Health Services Division
Washington State Department o~ Corrections
P.O Box41123
Olympia, WA 98504-2113
To be filled out by DOC Physician:
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, have reviewed this verification form a rnd that use of medical marijuana by this patient
(check one) lOis . IS not .
con~[stent 'Nith QOC ~::;oticy'. 1
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,Physician-sN"uTie'(printj " ,.-.-_. --~. -----:--
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PhySician!s Signature .
Date
'Instructions, to DOC Physician:
When form is complete:
,1. Email your finding above to the Assistant Secretary for Community Corrections_
2" File this form and the accompanying Release of Information in Liberty as a Community Corrections Health Record.
State law (RCW 70.02; RCW 70.24.105; RCW 71.05.390) andlor federal regulations (42 CFR Part 2; 45 CFR Part 164) prohibit
disclosure of this infomiation without the specific written consent of the person to whom it pertains, or as otherwise, '
permitted by law.
'
PDU-6655-3 000226