DOC request three complete - Cannabis Defense Coalition

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Prescrtbe sName (Print) ,
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License #: }if]) (}} 60 I 1(" 3 / . I License type: --=M:.!:...!1-..!D~· _________ _
Prescriber's Address
2//5" e, iA/;;:) 5 iDYl 1f1tJ' Phone Number
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Prescriber: p!ease n~t!.lm"fh;s form and the p~tlent's Release of Information to:
Medical Director
Health Servlces DiVision
Washington State Department of Corrections
PO Box 41123
. Olympia, INA 98504-2113
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To be filled out by boc Physician:
I have reviewed this verification form and find that use of medical marijuana by this patient
(check one) lOis 0 is not . .
consistent with DOC Policy. . .
Pllyslcian's Name (Print)
PhYSician's Signature
Date
.i·
. Instructions to. DOC Physician:
When form is complete::.
1. Email your finding above to the Assistant-SecretarY for Community Corrections
2. File this fo~m and the accompanying Release of Information in Uberty as a Community Gorrections Health Record ..
State law (RCW 70.02j RCW 70.24.105; RCW 71.05.390) and/or federal regulations (42 CFR Part 2; 45 CFR Part 164) prohibit
disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise
permittee! by law.
DOC 14.iJS3 (Rev. 7/31/08) DOC 380.200
PDU-6655-3 000365