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DOC request three complete - Cannabis Defense Coalition

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J 63/64/2669 14:18<br />

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'"<br />

2654185559 .<br />

CBR MEDICAL<br />

PAGE' 62<br />

STATE OF. WASHINGTON<br />

DEPARTMENT OF CORRl'!C'l'IONS<br />

AUTHORIZATION FOR DISCLOSURE<br />

TION<br />

Ol'~ENOF.R 1.0. OA'I'A:<br />

hereby authorl%e the use or disclosure of my health Information<br />

~rn"'lii.,.

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