DOC request three complete - Cannabis Defense Coalition

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Prescriber's Name (Print)
License #: MO 0 0 0 / t:3 / I License type: -..""-A_tft....._p
_____ ~_
Prescriber's Address . 3/1!:£ e .Illas· -;,JQ a 411 of
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Prescriber: please return this form and tile patient's Release of Information to:
Medical Director
Health Services Division
Washington State Department of CorrectiQn~
PO Box 41123
Olympia, WA985D4-2113
Phone Number
500· 5'7{) .. ;J-CJ" 8'" fa
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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 not .
consistent with DOC Policy.
Physician's Name (Print)
'Instructions to DOC Physician:
When form is complete:
Physician's Signature
1. . Email your finding above to the Assistant Secretary for Community Corrections
2. File this form and the accompanying Release of Information in Uberty as a Community Corrections Health Record ..
Date
,
j
I
------~--------.-.-.---.-------..:...-.--- ',---
, .
State law (RCW 70.02: RCW 70,24.1 05; RCW 71.05.390) and/or federal regulations (42 CFR Part 2; 45 CFR Part 164) prohibrt
disclosure of this Information without the specific written consent of the person to whom it pertains, or as otherwise .
permitted by law. .
oqc 14-053 (Rev. 7/31/08)
DOC 380.:200
PDU-6655-3 000269