DOC request three complete - Cannabis Defense Coalition

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Prl!scribe~s N;me (Print) Preserlber's Signature .
License #: ..jM D 0 0 0 t 3 I I License type: -=A--'-=v"--_____ ---, ___ _
Prescriber's Address :3 f { S- E. 1k1" 5-;',' D () 4,; f' . Phone Number
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Prescriher: please rewrh this form and the patienfs Release of Infonnation to:
Medical Director
Health Services Drvrsion
Washington State Department of Corrections
PO Box41123
Olympia, WA 98504-2113
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To be filled oot by DOC Physician: ..
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I have reviewed this verification form and find that use of medical marijuana by ihis pati~nt
(check one) lOis [1]15 not
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1 consistent with DOC Policy. !
'Physioian's Neme (Print) .
F>l1ysfolan's Sig."liIture
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,Instructions·to DOC Physician:
When form is complete:
1. Email your finding above to the Assistant. Secretary for Community Cqrrectlons .
2. File this form and the aocompanYing Release of Information in Liberty ;;lS a Community Corrections Health Record.
State law (RCW 70.02; RCW 70.24.105; RCW 71.06.390) and/or rGderal regulatloll$ (42. CFR Part 2; 45 CFR Part 164) prohibit
disclosure of this infonnatiQn without the specific written (:onsent of the per.son to wl10m it pertains, or as otherwIse
permitted by law.
DOC 14-053 (Rev. 7/31/08) DOC 380.200
PDU-6655-3 000296