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OFFENDER 1.0. DATk STATE OF WASHINGTON DEPARTMENT OF CORRECTIONS AUTHORIZATION FOR DISCLOSURE OF I i I ,. r t i : :. . : Purpose for disclosure: Co mliJ , {, 'g r'7 C « I understand that the information in my health record may include information relating to sexuaily transmitted infections, Acquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse. This information may be disclosed to and used by the following individual or orgaJlif:ation: . NAME: ttkg h,',yt" '3ftd < Dp-r '" {2 U (f'e c. L J VI. .s ADDRES& __________________ ~------------------ I understand that f have a right to revoke this authorization at any time. I underst;;jnd that if I revoke this authorization I must do so in writing and present my written revocation to the Health Information Management Department. I understand that the revocation will.not apply to information that has already been released in . response to this authorizatiOjl' Unless otherwise revoked, this authorization will expire on the following dat~, event, or condition: ,,:6 ('1 f-O
Or-FENDER 1.0. DATA, j' STATE OF WASHiNGTON DEPARTMENT OF CORRECTIONS Medicinal Use of Marijuana Verification Dear 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 patient is currently under supervision by the, ' Department Supervision is designed to help the offender avoid those environments or situations that lead to their crimina! 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 drugs, including marijuana. This offender has claimed tIJat they have a condition for which the med,ieina! use of marijuana has been recommended. The bel,ow verification is to determine the legitimacy of their claim. Thank you in advance for your . assistance. If you have questions please feel free to personally contact the Medical Director of the Department at (360) 725-8700. ' ' ./ 1· - , 1, Is this patient under your care ~s 0 No ,., 2. Are you recommending medical marijuana for his patient due to a diagnosis of ACquired Immunodeficiency Syndrome (AIDS) DYes ~ a, If the answer to question 2 is "Yes", does he/she have anorexia E1'I'es -UNo b. If the answer to question 2a.is "Yes", does he/she have weight loss ' D'H!S ' DNa 3,' Are you recommending medical marijuana for this patient due to nausea and vomiting associated with cancer chemotherapy DYes ~ a. ' If the answer to question 3 is "Yes", has the patient failed to respond to conventionai antiemetic treatments G·~1'e5 ElI'ttJ b. if the answer to question 3a is ~es", please describe what those treatments were (medication, dose, duration): ' , tv' j/\ . 4. c, a, What is the planned schedule of chemotry:rapy " N/~" If you answered "No' to items 2 & 3 above, what is the r~ason you are 'recommending medicinal ure :";Tf, marijuana '. S e,e... '-- (.\~ .. _:.:.'- . N ... \
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Page 37 and 38: j I Documentation of MedicarAuthcir
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Page 41 and 42: Chapter 69.51 A RCW: Medical marij1
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