DOC request three complete - Cannabis Defense Coalition

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STATE OF WASHINGTON DEPARTMENT OF CORRECTIONS AUTHORIZATION FOR DISCLOSURE OF HEALTH Ihlr:r)~~IA OFFENDER 1.0. DATA: , hereby authorize the use or disclosure of my health information indiividW'lI.or organization is authorized to make the disclosure: NAME: -----"C~B!...LtC.-"----=d~'A~tlWL:J!o.,. .L-··...k· ~.=_(_' _,.--_ ADDRESS: __ ~:S~iLI_S:~~~~~~~~_'-L~~(~'~S~~~;~I~'b~~L __ ~~~v/~e ___ 5P t'ai/l(J i tL)&t. 7' 1207 Purpose for disclosure: ~ Y I' - F'l '. j . ~.;...' -f ,'. I~qql +0 (A'S(f' poSS""~.s c
''' .. r.~ l~} STATEOFWASHINGTON "1.JIiUL,- DEPARTMENT OF CORRECTIONS . Medici~al Use of Marijuana Verification OFFGNDER 1.0. DATA: To be fillE1d out by Prescriber: 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 of 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 ifs 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 marijuana 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) 725-8700. .'. '"/ . 1, . Is .this patient under yourcare ' . ~s D No 2. Are you recommending medical marijuana for his patient due to a diagnosis of AcqUired Immunodeficiency Syndrome (AIDS) a. b. If the answer to question 2 is "Yes", does he/she' haVe anorexia If the answer to question 2a is "Yes", does he/she have weight loss 3. Are you recommending' me'dlcal marijuana for this patient due to nausea and vomiting associated with cancer chemotherapy . DYes r;pr-es . D4'e! DYes CI blo blNo a, If the answer to question 3 is 'Yes", has the patlent failed to respond to conventional ~_ 0 No antiemetic treatments . b. If the answer to question 3a is "Yes", please descr"ibe what those trea.tments were (medication, dose, duration): . . N ~ .{'::\ p~::ue.\\: '. 4. c.' What is the planned schedule ofchemotherapy . . N,~ r~i'pp'\-::V:~ \~ If you answered "No" to items 2 & 3 above, what is the reason you are recommending medicinal use 9 f marijuana '. . S e.\!.' c. ~c-,-~;: ~ ...... C\:~:"t /VI:,~ r, I 5 .. a. Please proV;de evidence published in a peer-reviewed SCientific publication to support the medicinal use of marijuana for this purpose . ' .. ,::>.... '\ "f-\;.'\~~'V!'" .' .s~ ~ e n- c.. '- N. c While on community supervision ("parole") the Department of Corrections o~ly aut~oriz~s t~e use of the oral synthetic formulation of marijuana. If the Department ~ut~onzes ~hls patients. . use of medical marijuana, will'you be prescribing only the oral synthetiC formulation 0 Yes 6. The patient's accompanying Release of Information authorizes you to provid~ the . . Department with current and future information related to this issue. Do you agree to notify the Department's Medical Director of any changes in your answers above DYes <strong>DOC</strong> 14·053 (Rev. 7/31/08) OOC3eO.200 I .. PDU-6655-3 000032
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