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p0 ~ .(.%1>(" j I-/. Prescrtbe sName (Print) , )tLri_. _ License #: }if]) (}} 60 I 1(" 3 / . I License type: --=M:.!:...!1-..!D~· _________ _ Prescriber's Address 2//5" e, iA/;;:) 5 iDYl 1f1tJ' Phone Number "':Sf' () t: C2 A€ Wq 99202- 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 J.,', 52J1- 5"7D-.J-{8-j, §"o9-.2t-/ Z .. Y(02c./· 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
STATE OF WASHINGTON DEPARTMENT OF CORRECTIONS P.O. Box 41100 • Olympia, Washington 98504·1100 January 26, 2009 , i I DeaiMr._ Your Medicinal Use of Marijuana request was received on December 23, 2008. Upon review by the Department of Corrections' Health Services physician, your request has been denied.' You may appeal this decision by sending your written request within 15 business days' of this letter, which is on or before February 16, 2009. Please send your request to the address below: Karen Daniels, Assistant Secretary Community Correction,s Divi~ion Department of Corrections P.O. Box 41126 Olympia, WA 98504-1126 Your request must provide additional hlormation that was not .included with your original request. Appeals that do not contam new infomiation will be denied, You will receive a response to your ~ppea1 request within 30 days of receipt. ) Sincere .,/.' .... '~Ii- / .. ~1~" Of ~ ,/ Karen D~ s, Assistant Secretary I Community 'Corrections Division KD:md . cc: Jim Kathan, Community Corrections Supervisor Michael-Anclerson,8ommuni:ty.8orrections-0fficel"---------------------- Field File Physician's Office: Attn: Melissa Leggee CBRMedical 3115 E. Mission Ave. Spokane, WA 99202 " Working Together for SAFE Communitj~s" PDU-6655-3000366
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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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.,.,... ..,..,.~ f~J STATE OF WASHI
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Nov. 26. 2008 4:37PM CBR Medical In
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.~. :.' '. ATTEN1':tON LAW ENFORCEM
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Wheeler, Judine L. (DOC) From: Sent
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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, Moriica J. (DOC) From: .
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j I Distefano, Monica 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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Nov, 26, 2008 4:39PM CBR Medical In
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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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Dec .. l0. 2008 1:34PM CBR Medical
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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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I. 1 Distefano, Monica J. (DOC) Fro
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STATE OF WASHINGTON . DEPARTMENT OF
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OCT/08/2008/WED 01: 39 PM Tael FAX
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.Distefano, Monica J. (DOC) From: S
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~ec. 23. 2UUB 9:U,PM' (;~K Medj'cal
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Dec.23. 2008 5:07PM ,CBR Medical In
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04/15/2009 18:28 4258696378 THCF PA
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. I, Offender Name STATE OF WASHING
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PDU-6655-3 000236
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Page 323 and 324: Distefano, Monica J. (DOC) From: Se
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Page 331 and 332: #fOr~ . .,;f ~ . {rri'~l STATEOFWAS
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Page 345 and 346: Distefano. Monica J. (DOC) From: Se
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Page 359 and 360: OFFENDGR I,D, DATA: STATE OF WASHIN
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Page 367: OFFENDER 1.0. OA·I.o.: STATE OF WA
Page 371 and 372: MARIJUANA MEDICINE- EVAlUATtON CENT
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Page 393 and 394: OFFENDER 1.0. DATA: STATE OF WASHIN
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STAT!: OF WASHING"ON DEPART1\lIENT
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I I , Smith, Sherri K. (DOC) From:
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February 17, 2009 STATE OF WASHINGT
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Jan, 4, 2009 12:41PM CBR Medical In
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Dec.30. 2008 12:20PM CBR Medical In
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DOC request three complete - Cannabis Defense Coalition

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