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I " IFax· CBR M~difcal,. Inc 3115 E. Mission Ave Spokane, WA 99202 o Urgent o For Review 0 Please Comment 0 PIQasli~ Reply 0 Please Recycle I i i I ! i I I ; 'Comments: j f GSRMedical, Inc. ~ 3115 E. Mission Ave, Spokane, Wa 99202 . Seattle Phone 206~774-6493 Fax 206-418-6659 Spokane Phone 509-242-8624 Fax 509-340-2710 Tri-Cities Phone 509416-2267 Fax 509-340-2710 Vancouver Phone 360-635-6464 Fax 206-418-6659 CONFIDENTIALllY NOTICE: This communication is intended for the sole use of the individual and entity' to wl!om It is addressEld' and may' contain informatiol1 that is privileged, or confidential and exempt from disclosure under applicable law. You are hereby notified that any dissemination, distribution, or duplicati~)O of this communication by' someone other than the intended addressee or its . designated agent is strictly prohibited. All infomnation is Protected Under U.$. Federal Law PDU~6655-3 000279
J. I OFFENOER 1.0. DATA: , . STATE OF WASHINGTON .- DEPARTMENT OF CORRECTIONS Medicinal Use of Marijuana Verification Pali I' To be fiUed out by Prescriber: 1--------J-1._~~~9.---LIIiiaI:---. ---J Dear Prescriber, By state statute the Washir.1gtcin State Department of Corrictions i$ .c.harged with tne reSporjsib!11W to supervise some offenders after they have been convicted of a felony. The above named patient is c.l,lrrently ·unde-i· supervision by the· Department. Supervision is designed to help the offender avoid those environments or situations 'that lead to their criminal behavior. Often illicit drug use is a .contributing factor in an indiv(dual's crimirialitY:··Accordingly its usual that the court or the Department of Corrections will impose a condition of supervision that the offender not use, or possess illicit drugs, including marijuana. This offel1der has claimed that they have a condition for which the medicinal use of marijuana has been recommended. The below verification is to determine the legitiinacy- of their ctaim. Thank you in advance for your assistance. If you have questions. please feel free to personally contact the Medical Director of the Dezartme at (~6.0) 725-8700. .' " . 1. Is this patient under your care' es '0 No 2. 3. 5. Are you recommending medical marijuana for his patient due to a diagnosIs of Acquired 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 Are you recommending medica! marijuana for this patient due to nausea and vomiting associated with cancer chemotherapy a: If the answer to question 3 is ''Yes'', has the patient failed to respond to conventional antiemetic treatments . . .: DYes DYes DYes DYes .~ ~. ~~ DYes· ~ b. If the a.nswer: to question 3a is 'Yes", please descrIbe what those treatments were (medication, dose, duration): \. / c. t,L V . What is the planned schedule of chemotherapy. I , t If yo~ .answered ")'10' to i\ems 2 & 3, above, what is the reason you ar~ recommending medicinal use of marijuana akv'o~, ~ p aV-J.....l tv' ~\..L.rc-e=-./ 4JI /fJSS .~ . . a. Please provide evidence publl~hed in a peer-reviewed scientific publication to sup ort th edi~lnal use of : m'arijuaha"fcfnhis purpose .... rfJie:.": . !>*-.J.
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STATE OF WASHINGTON DEPARTMENT OF C
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RECORDS PROVIDED WITH REDACTIONS ~~
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eRR Medical, Il1c 3115 E. Mission A
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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 DEPARTMENT
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STATE OF WASHINGTON .DEPARTMENT OF
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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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Distefano, Monica J: (DOC) From: Se
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Documentation of Medical Authorizat
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