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THCF Medical Clinics 1813 130 th Ave. NE #210· Bellevue, ·WA 98005 Phone: 425-869-6186 or 800-723-0188 iRECEfVED liAR 0 3. 2009 Dept of Corrections Health Services RECEIVED Fax: 425-869-6378 MAR' 0" 2009 . www.tht-foundation.orq. www.hemp.orgDAPt,p10;1rreCtIOn~ Documentation of Medical Authorization to Possess Marijuana T~~'cf1ltra9Jc;~ts Purposes in Washington State The text of this form was recommended by the Washington State Medical Association. s Patient Name: Date of Birth:--=.u. I, Thomas Orvald, am a physician licensed in the State of Washington. I am treating the above named patientfor a terminal iHness or a debilitating condition a's defined in the RCW 69.51A.OIO. I have advised the above named patient about the potential risks and benefits of the the medical use of marijuana. I have assessed the above named patient's medical hi;;tory and medical condition. It is my medical opinion that the potential benefits of the medical use of marijuana would likely outweigh the health risks :for this patient. . Signature of Physicia~: --,:,::--_. ~---I!-==~:;..J' ~~,,:......:......,..,-.~=-()--,~,.....,....,...u--:---:-~_--,-_c_th Thomas Orvald, MD WA #. MD 00016180 . __· (;,_(_'" Today's Date: i.j@JY)H~D~ I Q . .gOO 1'· Expiration Date:,. YLXVU,1aeJ if:) 020/0 Risks and benefits of medical marijuana: 'Under Washington state law, the use of medical marijuanais now permissible for some patients with terminal or debilitating illnesses. The laws regulation this (RCW 69.51A.) .allows physician's 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 'safeor effective and some providers feel that it is a dangerous drug. According to the Washington state law the benefits of medical marijuana may include treating nausea and vomiting from chem,otherapy; AIDS wasting syndrome; severe muscle spasms from multiple sclerosis or other spasticity disorders; glaucoma; and some types of intractable pain. Some of the ris!
01/21/2008" 20:06 2534724155 VEHICLE PICKUP PAGE 02/04 /"" .... , l~ STAT!; Cf"WASHINGTON ~ CeARTMENT OF CORReCTIONS Medicinal Use of Marijuana Verification OFFENDER 1.0. OATA: To be iiiiea oui: by Prescriber: Dear Prescriber, By state staMe the Washington State Department of Corrections is charged with the responsibility to supervise some offenders after they have been convicted of a felony. The above named patient is currently under supervision by the Dgparirnant. Supervision is designsd to help the offender avoid those environments or situations that lead to t'1eir criminal behavior. Often illicit drug use is a contributing factor in ari individual's criminality. Accordingly it'susuaf that tne court or the Department of Corrections will impose a condition of supervision that the offender not use, or possess illicit drugs, including marijuana. This offender has claimed ·that they have a condition for which the medicinal use of marijuana has been recommended. The below verificafion is to determine the legitimacy of their claim. Thank you in advance for your
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STATE OF WASHINGTON DEPARTMENT OF C
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RECORDS PROVIDED WITH REDACTIONS ~~
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(".- " ~"""'":.~ Inr ... ~ STATEOFW
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i ( Documentation of Physician Auth
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Distefano, Monica J. (DOC) From: Se
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eRR Medical, Il1c 3115 E. Mission A
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Fax : ' 3115,E. Mission Ave Spokane
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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 DEPA'RTMENTOF C
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311S'E. Mission Ave Spokane, WA 992
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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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Chapter 69.511). RCW: Medical111ari
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OFFENDER 1.0. DATA: STATE OF WASHIN
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Prescriber's Name (Print) License#:
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3115 E. Mission Ave Spokane, WA 992
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. ! STATE OF WASHINGTON DEPARTMENT
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STATE OF WASHINGTON .DEPARTMENT OF
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T.)' ~x.. MARIJUANA MEDICINE'· 'EV
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Wheeler, Judine L. (DOC) From: Sent
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I I do ncit want to ruffle feathers
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Interpretation of Medical Marijuana
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From: Sent: To: Duggan, Brenda J. (
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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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3. High Non-Violent 4. Moderate, an
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Distefano, Moriica J. (DOC) From: .
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E.... KIOSK reporting may be used i
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to be processed now. If this was re
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11/06/2008 13:05 - PAGE ./"""-1. II
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Stern, Marc F. 'Dir Hlth Svc' (~OC)
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I J i Date License type: Prescriber
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Distefano, Monica J: (DOC) From: Se
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STATE OF WASHINGTON . DEPARTMENT OF
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OFFENDER 1.0. DATA: STATE OF WASHIN
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February 17, 2009 STATE OF WASHINGT
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