DOC request three complete - Cannabis Defense Coalition

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(~ STATE OF WASHINGTON
....., DEPARTMENT OF CORRECTIONS
AUTHORIZATION FOR DISCLOSURE
OF HEALTH INF:ORMA
EVANS, TRISTA R.
324594 11/04/1974
518087679 .
___ , hereby authorize the use or disclosure of my health Information
to make the disclosure:
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The type and date(s) of information to be used or disclosed is as follows:
Purpose for dlsolosure:, _____________ ..,._----------..,._--------
I understand that the Information In my health record may Include informatldn relating to sexually transmitted .
infections, Acqu!red Immu~,defi~ienoy Syndrome (AIDS). or .rjy~nJ,mmunodeficien~ Virus (HIV). It may also'"
Include,.!D!orF!l.ru~;EI~out~l5'tii/i\a\1loral. C!r. !ll~.m~1 hea.lth ~~f,Yr~ tr~atm.!!lJ.tfQr alcohol a\'ld .. 9~1.lS-~I:l~!,:,_ ~ ...... _. __ ._ ....... .
This Information may be disclosed to and used by the following individual or organization:
Medical Director
Health Services Division
NAME: WashllTll'lion State Department Of Correc1ions
POBox41t~
ADDRESS: Olympia, WA ')l594=2113
I understand that I have a right· to revoke this authorization at any time. I understand thatif I revoke this
authorization! 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 authorization. Unless otherwise revoked, this authorization will expire on the following date, event,·
or condition: . . (if left blai"ik, authorization wiil expire six {B) months from signing).
I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this
authorization. I need not sign this form In order to assure treatment. I I.,Inderstand that I may Inspect or copy the
information to be used or disclosed. as provided In CFR 164.524 and RCW 70.02. ! understand that any disclosure.
of Information carries with it the potential for an unauthorized redisclQSLlre and may not be protected by federal or
state ccnfideli'Jaiity rules. If I have quesi:ions about disclosure of my health Information, I may contact the
RHITfdesignee of the facility: . =~:::::::1·:;;:::;:",1-7.;-OL.--.--- . ___ ........ _ ..
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