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STATE OF WASHINGTON DEPARTMENT OF CORRECTIONS Medicinal Use of Marijuana Verification OFFENCER I,D CATA: I I I ! j Dear Prescriber, By state statute the Washington state Department of Corrections is charged with the responsibility to supervise some offenders after they have been convicted qf a felony., The above named patient is currently under 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 individual's criminality. Accordingly it's 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 offender has claimed that they have a condition for which the medicinal use of marijuar.Ia has been recommended. The below verification is to determine the legitimacy of their claim. Thank you in advance for your assistance. If you have questions please feel free to personally contact the Medical Director of the Department at (360) ~~' / ' 1. 15 this patient under your care /2Nes 0 No 2. Are you recommending medical marijuana for his patient due to a diagnosis of Acquired Immunodeficiency Syndrome (AIDS) , 'e. If the answer to question 2 i~ "Yes:', does he/she have anoraxia b. If the, answer to question 2a is "Yes", does he/she have weight loss 3. 'Are you recommending medical marijuana for this patient due to nc~usee and vomiting associated with cancer chemotherapy 4. a. If the answer to question 3 is "Yes", has the patient failed to respond to conventional antiemetic treatments r [ V DYes DYes DYes DYes DYes b. Ifthe answer to question 3a is ·Yes", please describe whatthose treatments were (medication, dose, duration):' c. What is the planned schedUle of chemotherapy I a. , ,;VI~ If you answered "No" to items 2 & 3 above; what is the reason you are recommendingomedicinal use of marijuana' 'n I\.. r, j ~ ~ .' cJ~, h~'I""~' ~ "'---' ' ~ ~' ~ Z No' Please prov.ide evidence published in a peer-reviewed scientific publication to support t.he medicinal use of' marijuana for this purpose " _ () • ----~----.-'-------~.,J-e...~ ~~~\~ i i· 1 I 5. While on community supervision ("para Ie") the Department af Corrections only authorizes the use of the oral synthetic formulation of mariJuana. If the Department authorizes this patient's use of medical marijuana, wlilyou be prescribIng only the oral synthetic formulation 6. ,The patient's accompanying Release of Information authori~e~ you to provide the . Department with current and future information related to this Issue. Do YOll agree to notify the Department's Medical Director of any changes in your answers above DYes DYes <strong>DOC</strong> 14-053 (ReV: 7/31/08) <strong>DOC</strong> 380.200 PDU-6655-3 000333
. p(J !/j~1 ·.;IS-.·j / Prescriders Name (Print) .~ ! !\ ,"- License #: f/!} boo Q / \("3// License type: . A.4.D ~~~~-------------------- Prescriber's Address '"3/(5" E-iU,'5S,'G)~ fivp . Phone Number . 5fv ..qn.o r vJC'/. Cfq z@ z.. Prescriber: please return this form and tile patient's Release of Information to: . Medical Director Hea!th Services Division Washington State Departmentof Corrections PO Box 41123· Olympia, WA 98504-2113 , \ SOc;· 570";2-·8'"""66 Seq ~ .J-
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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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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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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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Interpretation of Medical Marijuana
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Date & Tirpe Created: 12/16/2008 11
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I J i Date License type: Prescriber
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