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Documentation of Medical Authorization to Possess Marijuana for Medical Purposes in Washington State PATIENT NAME: ___ _ DATE OF BIRTH:~ I, Dr: Mohammad H. Said , am a physician licensed in the State of Washington and I am treating the above patient for a terminal illness or a debilitating condition as defined by RCW 69.51A010. . . . ·1 have advised the above named patient about the potential risks and benefits of the medical use of marijuana. I 'have 'assessed the above named patient's medical history and medical condition. It is my medical opiniori that the potential benefits of tI]~ medical use of marijuana may outweigh the health risks for this patient. .... . .. Physician Name: ~_'D::::.r:.:. .:.::M.:.::o~h=a!..!.m!!..!mc!.::a:.::d:..!H..!.:.:..!S::.::a:.::id::...-__ WA License Number:, __.:.:M:.:.:D~0:..:0:..:0..:.1.:.83=-1.:...;1_ Ph ySlclan •. S· , fA.A. /-1. S ~f Ignature: _,--..£.f_ -_... ---:~______ Date: _-'-. ~02:::.;/2==2::..:/2::..:0:..::;O,;:.9 __.--:. This re~ommendation expires on: 02/22/2010 Risks and banaf(ts of medical marijuana Under Washington law, the lise of medical marijuana is now permissible for some patients with terminal or debilitating illnesses. Tlie law regulating this (RCW 69.51 A) allows physicians to advise patients about the risks and benefits 'of the medical use of marijuana. The medical and scientific evidence supporting the use of medical marijuana remains controversial in the medical community. Not all health care providers believe that medical marijuana is safe or effectjve arid"~ome providers' feel that it is 'a dangerous drug. According totO$:! Wa$hihgti.:m State law the benefits of medical marijl,.lana may include treating nausea ancfvoniiting fr'Om chemotherapy, AIDS wasting syndrome, severe mus~le spasms from multiple sclerosis or other spasticity disorders, glaucoma, am:,1 some types of intractable pain: , Some of the risks of medical marijuana may include possible long-term effects of the brafn in the areas of memory, coordination and cognition; impairment of the ability to drive or operate heavy machinery; respiratory damage; possible lung cancer; and physical or psychological dependence. I "; I I ! Recommendation As this patient's ;'60 Day Supply", as,'stipulated ,by RCW 69.51A.040 (3)(b) and ------WAC246-7-5-Q.:1.Q,this-Qualify.ir:Jg-l2atier.lt-car.l-t:6aSor:lably..expect,.to_ba~e..in...their.Eoses.sioJLao.d'__ ~ __ i--_ Need a total of no more than 24 Ounces of "Useable Marijuana" and no, more than 15 Plants. CBR Medical, Inc. . Administrative Office 3115 E. Mission Ave, Spokane, WA99202 , 1· 1 I [ I Spokane: 509-242~624 Fax:509-340-2710 Seattle: 206-774-6493 Fax: 206-418-6659 EMERGENCY OR LAW ENFORCEME;NT ONLY CALL 509-570-2886 OR 509-570-6943 ; PDU-6655-3 000281
STATE OF WASHINGTON DEPARTMENT OF CORRECTIONS P.O. Box 41100' Olympia, Washington 98504-1100 March 26, 2009 Your Medicinal Use of Marijuana request was received on March 4,2009. Upon review by the Department of Corrections' Health Sl'lrvices physician, your request has been denied. You may appeal this decision by' sending, your written request within 15 business days, on or before April!7, 2009.' Please send your request to the address below: ' Karen Daniels, Assistan~ Secretary Community Corrections Division Department of Corrections P.O. Box 41126 Olympia, WA 98504-1126 Your request must provide ,additional information that was not included with your original request. Appeals that do not contain new information will be denied. You will receive a response to your appeal request within 30 days of receipt Karen Daniels, Assistant Secretary COll1l1unity Corrections Division KD:md cc: Carole Rigney, Community Corrections Supervi'sor Steven Burriss, Community Corrections Officer Field File Physician's Office: Attn: Melissa Leggee CBR Medical, Inc. 3115 E. MIssion Ave. , Spokane, WA 99202. , " Working Together for SAFE Communities" 0. recycled paper PDU-6655-3 000282
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STATE OF WASHINGTON DEPARTMENT OF C
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i ( Documentation of Physician Auth
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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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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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OFFENDER 1.0. DATA: STATE OF WASHIN
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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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NIELSEN TO COME UPSTAIRS. CCO NIELS
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Date & Tirpe Created: 12/16/2008 11
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OFFENDER 1.0. DATA: STATE OF WASHIN
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Documentation of Medical Authorizat
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