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,------------------------------ -----------------_._- Jan. 23. 2009 11: 49AM CBR Medical Inc. No.3192 P. 2/6 STATe OF WASHINGTON DEPARTMENT Of CORRECTIONS AUTHQRlZATION FOR DISCLOSURE OF INFORMATION I)FFFNfJer! 1.1' DAr", hereby authorize the USB Or disclosure of my health information or organization is authorized to make the disclosure: ';A""" C~ 11: .•") (;:,/ 'f,;'" \. _ !1 '-t'" ( I,. Ivlc: ... ~ ~~'-:1"r== ,{ weI {
·· ! Jan. 23. 2009 11 :49AM CBR Medical Inc. No.3192 P. 3/6 OFI'ENOCR I.ll nATA' STATE OF WI'SHINGl·ON DEPARTnOENT OF CORRECTIONS Medicinal Use of Marijuana Verification To be filled out by Prescriber: Dear Prescriber. l3y 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 sl,lpervision by the Department. Supervision is designed to help the offender avoid those environrnents or situations that lead to their criminal behavior. Often illi~it drug LIse is a contributing factor in an individual's Criminality. Accordingly it's usual that thei courtor the Departmerit of Corrections will impose a condition of supervision that the offender not LIse. or possess iUicit drugs, including marijuana. This offender has claimed that they have a condition for which the medicinal use of marijuana has been recommended. The below verification is to determine the legitimacy of their claim. Thank you in advance for your assistance. If you have questions please feel tree to personally contact the Medical Director of the Oepartmef]t at (360) ~~ / 1. Is this patienl under your car~ 1L:1Yes UNo /"" 2. 3 Are you recommending medical marijuana for his patient due to a diagnosis of AcqLlired Immunodeficiency Syndrome (AIDS) a. If the answer to question 2 is "Yes", does he/she have anorexia b. . If the answer to question 2a is ,"Yes', does he/she have weight loss DYes Are you recommending medical marijilana for this patient due to nausea and vomiting DYes associated with cancer chemotherC!PY 8. If the answer to quastion 3 is "Yes",·has the patIent failed to respond to conventional antiemetic treatments . b. If the answer to question 3a is "Yes", please describe what those treatments were (medication, dose, duration): \ t\....... . N ...),;. \'\ fr \ \ V:.. \.'\ t- c. What is the planned schedule of chemotl1r;rapy ~ ,.. iy (;:\ fr\; ll:.1 \-l. I.~ ElTes-a-No Q-.¥es-~.'--B~No ... ~' 4. If you answered "No" to items 2 & 3 above, what is tile reaSOn you are recommending. medicinal use of - • 'l marijuana j' "\ \ \ .... . . . I,. ( ..... , '> J\J\I \.... ec~ .t~","t\........ \-I\!..':: C.l3R. -.f""'''1('~''..",..,,, "---" ........
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STATE OF WASHINGTON DEPARTMENT OF C
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RECORDS PROVIDED WITH REDACTIONS ~~
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(".- " ~"""'":.~ Inr ... ~ STATEOFW
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i ( Documentation of Physician Auth
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Distefano, Monica J. (DOC) From: Se
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eRR Medical, Il1c 3115 E. Mission A
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Fax : ' 3115,E. Mission Ave Spokane
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Or-FENDER 1.0. DATA, j' STATE OF WA
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DoCumentation of Medical AuthoriZat
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STATE OF WASHINGTON DEPA'RTMENTOF C
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j I Documentation of MedicarAuthcir
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Chapter 69.51 A RCW: Medical marij1
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Chapter 69.S1A RCW: Medical marijua
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3115 E. Mission Ave Spokane, WA 992
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. ! STATE OF WASHINGTON DEPARTMENT
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STATE OF WASHINGTON .DEPARTMENT OF
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T.)' ~x.. MARIJUANA MEDICINE'· 'EV
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Wheeler, Judine L. (DOC) From: Sent
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Interpretation of Medical Marijuana
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Date & Tirpe Created: 12/16/2008 11
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Documentation of Medical Authorizat
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