DOC request three complete - Cannabis Defense Coalition

License #:
,Prescriber's Address
License type:
Phone Number
Prescriber: please return this,form and the patient's Release of Information to:
Medical DirElctor
Health Services Division
Washington State Department of ,corrections '
PO Box 41123
Olympia, WA 9B504·2113 '
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To be filled out by, DOC Physician:' '
I have reviewed this verification form and find that use of medical marijuana by this patient
, (check one) lOis 0 is ncit ' ,
consistent with DOC ,PoliCY.
Physician's Name (Print)
Instructions to DOC Physici,an:
Physician's Signature
Wren 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.
Date
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State law (RCW 70.02; RCW 7Q,24,105; RCW 71.05.390) andforfederal regulations (42. CFR Part 2;.45 CFR Part 164t prohibit
disclOsure of this information without the llpeclfic written consent of the person·to whom it pertains, or as otherwise
pennitted by law.
DOC 14-053 (Rev. 7/31/08)
006380.200
PDU-6655-3000021