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I I. Documentation of Medical Authorization to Possess Marijuana for Medical Purposes in Washington State PATIENT NAME: ___ _ IATE OF BIRTH: ~ f, Dr. Mohammad H. Said , am a physician licensed in the State of Washington and lam treating the above patient for a terminal illness or a debilitating condition as defined by RCW 69.5'IA-OiD. . . ! have advised .tile above named patient about the pptential risks and benefits of the medical. use . of marijuana. I have assessed The above named patient's medical history a'nd medical. condition. ft is my medical opinion that the potential benefits of the medical use of marijuana may outweigh the health risks for tilis patient. Physician Name: __:;;,D",-r •.:.:M.:.:o:..;,il;::a:;,:m.::.m:.,:;a:;,,:d:;..:...:H:... S:::;a::..;i.::;,d ___/se Number: MD00018311 Physician Signature: ~'lf ~ c:u...
~r.~''''' OFFeNDER 1.0. DATA: ( ~ STATEOFWASHINGTOIII DEPARTMENT OF CORRECTIONS AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATJON hereby authorize the use or disclosure of my heal~h information or organization is authorized to make the disclosure: NAME: en \iL . \J\& _A~ c.... ..... \ . ADDRESS: __ ~~~~I~I_~~,~t::~·~.~.~c{~A~',~'·~S~~_d~;~·£>~'~~~~~~~~'l-__ __ ~.o.e C4 I\, I) I..A..9 0 '7" q Z. (') "2 . ~ l The type and date(s} of information to be used or diSC~O ed IS as fonows: . .,\ r. r" r\ --f- r 1\ ...J..... (,/ J Q., I~ C. "l !{(~)"\. 0 q- i~!...{ fi C ,7 Cdl i)h 6 ~ . c 5- ..i (p 7. I.IT i I I .I, Purpose for discJosure: ___\J'~e=-!..{'-.!...·; 4-p._·-,II-...:C=·;;;:"'~:.:'1_-1.'::';~·O:::::"':V'I.~-t."..":;,.~C=:,,,......,.
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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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OCT/ Oct. B. LUO~, 11: ::J9AM T ~co
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... ""'"'''' f~ STATEOFWA$HINGTON ~
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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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'.!, To: C!6R MedicaO,. h'IlC 31)5
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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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''' .. r.~ l~} STATEOFWASHINGTON "1
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j I Documentation of MedicarAuthcir
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, • J ' -1. d; z.. 00 g-' /Vo v.
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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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•• I ! 3115 E. Mission Ave Spok
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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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.,.,... ..,..,.~ f~J STATE OF WASHI
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.~. :.' '. ATTEN1':tON LAW ENFORCEM
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\"'Ior"'.~ OFFENDER 1.0. DATA: I f
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Wheeler, Judine L. (DOC) From: Sent
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OMNI: Chrollos Quick Search , •
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-...... THCF MEDICAL CLINICS 1813 1
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Prescdbar's Name (pnnt) . Prasc~jje
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I I do ncit want to ruffle feathers
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Let me know if you have questions f
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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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, ' ~. With Community Corrections S
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I FW: 380200 Community Supervision
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Distefano, Monica J. (DOC) · From:
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Distefano, Moriica J. (DOC) From: .
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E.... KIOSK reporting may be used i
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RE: 380 200 Community Supervision o
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RE: 380200 Community Supervision of
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to be processed now. If this was re
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FW: 380200 Community Supervision of
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Distefano. Monica J. (DOC) From: Di
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Documentation of Medical Authorizat
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Distefano. Monica J. (DOC) From: Se
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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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. I, Offender Name STATE OF WASHING
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PDU-6655-3 000236
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Page 319 and 320: OFFENDER I.D. DATA: STATE OFWASHING
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Page 343 and 344: i I Documentation of Medical Author
Page 345 and 346: Distefano. Monica J. (DOC) From: Se
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Page 371 and 372: MARIJUANA MEDICINE- EVAlUATtON CENT
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OFFENDER 1.0. DATA: STATE OF WASHIN
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I Prescriber's Name (Print) License
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Documentation of Medical Authorizat
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