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- , --, ---------, I i 03/04/2009 14:08 1 --------------------.. ------------------.--- 2064186659 CBR MEDICAL, PAGE 03 11""'~IIn"A,,~ .1" '\. l~) STATEOrWASHll-IGTON IIJIULr' DEPARTMENT OF CORREC'TlONS Medicinal Use of Marijuana Verification OFFIlNOER I,D. OATil! TO be fined out by Prescriber:' Dear Prescriber, By state statl:lte the Washington State Department of Correotions is charged With the responsibility to supervise some offenders after they have been c,onvicted of a felony_ The above named patient is currently under supervision by, the Oepartment Supervision is designed to help the offender avoid those environments or situations that lead to their criminal beha,,;or. 01ten illicit drug use is a confributing factor in an individual's crimil'lai1ty. ACCr;lrdingiy it's usual that the court or the Department of Correctlons will impose a condition of supervision that the Offender not use, or possess illicit drugs, including marijuana. This offender has claimed that they have a condition for which the medicinal use of marijuana has been recommended_ The below verifica1ion is to determine the legitimacy of their claim. Thank you in advance for yout aasistance. If you have questions please feel free to,personally contact the Medical Director of tne Department -at (360) 725-8700. '/ 1. Is this patfent under your care [] Yes D No 2. 3. Are you recommending medical marijuana for his patient due to a diagnosis of Acqulrecl Immunodeficiency Syndrome (AIDS) , a. If the answer to question 2,iS "Yes", does he/she have anorexia b. If the aMwer to question 28 is "Yes", does helshe have weight los!> , ' DYes , DYes DYes Are you recommending medical marijuana for this patient dlle to nausea and vomiting DYes associated with cancer chemotherapy . a. If the answer 10 question 3 is "Yes", has the patientfailed to respond to convGntional Dyes antiemetic treatments b. If the answer to question 3a is "Yes". please describe what those treatments were (medication, dose, duration): ~ rt; GNO ~ c. What is the pl13nned schedule of chemotherapy 4_ ' If you answered "No" to i\emS 2 &. 3 above, what is tht'O reason yo~re recommepding medidn~. ~ ft marijtlana', Q lA {o~ ; C. HLc..J.~ .. Yte'J, 'f(Sr~lttC...1 +. i>"'\"'V'. fU..d\. --tl~~ , . _______ ~ __ ~~~;~~~~~":;~~~brr~::;i~~~t~~bjt~~~rt ::~id",1 ~:~~_ ... 5. While on community supervision ("parole") the Department of Corrections only authorizes the , DYes use of medical marijuana, will you be prescribing only the oral synthetic formulation . , . 6. ' The patient's accompanying Release of Information authorizes you to provide the , Department with current and future information related to this issue. Do you agree to notify 0 Yes . No the Department's Medical Director of any changes in your answers above DOC 14-053 (I'(sv. 7J31J08) DOC 360.200 PDU-6655-3 000259
03/04/2009 14:08 2064186659 CBR MEDICAL PAGE· 04 Presorib(!r',. Signature . I.icense~: License type: PrescriJ:ler'sAddress ;51/5:.E:.. d'sS/"i)n Phone Number . SPI;) t:an.J.. W c.... 7' 7 t.. b t.. Prescr!ber: please return this form ~nd the patient's Release of Information to: 5l) Cf -,. '12 _.8'(P Z ~-( . 57)'7 - 5'7{) - d. ;r~~ Medical Director Health Services Di:vision Washington State Department of CorrectiOns PO Box 41123 Olympia, WA 98504-2113 To be fiiied out by DOC Physician: I have reviewed thisllerification form and find that use of medical marijuana b\l this patient (check on~) lOis. 0 is not . cons istent with DO.C Policy~ PhY$i
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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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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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. ! STATE OF WASHINGTON DEPARTMENT
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STATE OF WASHINGTON .DEPARTMENT OF
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Interpretation of Medical Marijuana
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From: Sent: To: Duggan, Brenda J. (
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NIELSEN TO COME UPSTAIRS. CCO NIELS
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Date & Tirpe Created: 12/16/2008 11
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PRIMARY CARE PHYSICIAN AND LOOKED O
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February 17, 2009 STATE OF WASHINGT
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