DOC request three complete - Cannabis Defense Coalition

More documents

Recommendations

Info

Prescribe~s Name (Print) Prescriber's Signature 1~-C-oV Date License #: lJ1 D b .0 D J ~ .3 / .1 License type: JY! 0 Prescriber's Address "")/.1 2- c" g. 55:.0"7 4~/t" Phone Number SiD ~, 1/1.( ,0"'
-.." OFFENDER 1.0. O"TA: jDE~ . i ~} STATE OF WASHINGTON . DEPARTMENT OF CORRECTIONS AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION I, , h'!lreby authorize the use or disclosure of my health information as described below. The following individual or organization is authorized to make the disclosur~: NAME: ADDRESS:----------~--------------------------- The type and date(s) of information to be used or disclosed is as follows: Purpose for disclosure:. ___________________________ .....:. __________________________ _ I understand that the information in 'my health record may include information relating to sexually transmitted infections, Acquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV). It may also include information about behavioral or mental health . , . • • • , •• ., This information may be disclosed to and used by the NAME:' ____ -=-__ _ ADDRESS: _____________ __ I understand that I have a light to revoke this authoriZl authorization I must do so in writing and present my w Department. I understand that the revocation will not· response to this authorization. Unless otherwise revo or condition: (If I I understand that authorizing the disclosure of this he, authorization. I need not sign this form in order to ass information to. be used or disclosed, as provided in CF of information carries with it the potential for an unautl state confidentlality rules. If [ have questlons about dl RHtT/deslgnee of the facility: nent I in ate, event, )m signing). 5 opy the disclosure ,deralor Signature of Patlent (Do not sign Ifform Is not complete) Date (Patient to complete) Social Security Number Date of Birth DOC Number Signature of Witness Date Slata law (RCW 70.02; RCW70.24.1 05; nCW 1.05.390) .and/or federal regulatlans (42 CFR Pari 2; 45 CFR Part 1(4) prohibit di.
Page 1 and 2:
STATE OF WASHINGTON DEPARTMENT OF C
Page 3 and 4:
RECORDS PROVIDED WITH REDACTIONS ~~
Page 5 and 6:
(".- " ~"""'":.~ Inr ... ~ STATEOFW
Page 7 and 8:
i ( Documentation of Physician Auth
Page 9 and 10:
OCT/ Oct. B. LUO~, 11: ::J9AM T ~co
Page 11 and 12:
, ( .....,-.\ ') ',. . ~'. ;' '-UVi
Page 13 and 14:
... ""'"'''' f~ STATEOFWA$HINGTON ~
Page 15 and 16:
Page 17 and 18:
Distefano, Monica J. (DOC) From: Se
Page 19 and 20:
eRR Medical, Il1c 3115 E. Mission A
Page 21 and 22:
Fax : ' 3115,E. Mission Ave Spokane
Page 23 and 24:
Or-FENDER 1.0. DATA, j' STATE OF WA
Page 25 and 26:
DoCumentation of Medical AuthoriZat
Page 27 and 28:
'.!, To: C!6R MedicaO,. h'IlC 31)5
Page 29 and 30:
STATE OF WASHINGTON DEPA'RTMENTOF C
Page 31 and 32:
.' .or", g u:,Se J f 'D. G4A() ~~ P
Page 33 and 34:
311S'E. Mission Ave Spokane, WA 992
Page 35 and 36:
''' .. r.~ l~} STATEOFWASHINGTON "1
Page 37 and 38:
j I Documentation of MedicarAuthcir
Page 39 and 40:
, • J ' -1. d; z.. 00 g-' /Vo v.
Page 41 and 42:
Chapter 69.51 A RCW: Medical marij1
Page 43 and 44:
Chapter 69.S1A RCW: Medical marijua
Page 45 and 46:
Chapter 69.511). RCW: Medical111ari
Page 47 and 48:
•• I ! 3115 E. Mission Ave Spok
Page 49 and 50:
OFFENDER 1.0. DATA: STATE OF WASHIN
Page 51 and 52:
I I l- I I tV!. tier f!! (VLA I 4.
Page 53 and 54:
~ra.4~ OFFENOcR 1.0. DATA: { ~ STAT
Page 55 and 56:
Prescriber's Name (Print) License#:
Page 57 and 58:
3115 E. Mission Ave Spokane, WA 992
Page 59 and 60:
. ! STATE OF WASHINGTON DEPARTMENT
Page 61 and 62:
STATE OF WASHINGTON .DEPARTMENT OF
Page 63 and 64:
T.)' ~x.. MARIJUANA MEDICINE'· 'EV
Page 65 and 66:
.,.,... ..,..,.~ f~J STATE OF WASHI
Page 67 and 68:
"'.... ~ . OFFENOeR 1.0. OATA: fnrt
Page 69 and 70:
-----------------------_ Brown, Dam
Page 71 and 72:
Nov. 26. 2008 4:37PM CBR Medical In
Page 73 and 74:
No'v, 26, 2008 4:48PM CB R Me d i c
Page 75 and 76:
.~. :.' '. ATTEN1':tON LAW ENFORCEM
Page 77 and 78:
\"'Ior"'.~ OFFENDER 1.0. DATA: I f
Page 79 and 80:
Wheeler, Judine L. (DOC) From: Sent
Page 81 and 82:
OMNI: Chrollos Quick Search , •
Page 83 and 84:
-...... THCF MEDICAL CLINICS 1813 1
Page 85 and 86:
Prescdbar's Name (pnnt) . Prasc~jje
Page 87 and 88:
- ...-------------- _._.-- _ ..----
Page 89 and 90:
I I do ncit want to ruffle feathers
Page 91 and 92:
Let me know if you have questions f
Page 93 and 94:
Interpretation of Medical Marijuana
Page 95 and 96:
From: Sent: To: Duggan, Brenda J. (
Page 97 and 98:
NIELSEN TO COME UPSTAIRS. CCO NIELS
Page 99 and 100:
Date & Tirpe Created: 12/16/2008 11
Page 101 and 102:
PRIMARY CARE PHYSICIAN AND LOOKED O
Page 103 and 104:
Distefano, Monica J; (DOC) From: Se
Page 105 and 106:
3. High Non-Violent 4. Moderate, an
Page 107 and 108:
, ' ~. With Community Corrections S
Page 109 and 110:
Page 111 and 112:
I FW: 380200 Community Supervision
Page 113 and 114:
FW: 380200 COInmunity Supervision o
Page 115 and 116:
Distefano, Monica J. (DOC) · From:
Page 117 and 118:
Distefano, Moriica J. (DOC) From: .
Page 119 and 120:
j I Distefano, Monica J. (DOC) From
Page 121 and 122:
E.... KIOSK reporting may be used i
Page 123 and 124:
RE: 380 200 Community Supervision o
Page 125 and 126:
RE: 380200 Community Supervision of
Page 127 and 128:
'---.- .... _-- _.,,-.... Distefano
Page 129 and 130:
to be processed now. If this was re
Page 131 and 132:
Page 133 and 134:
FW: 380200 Community Supervision of
Page 135 and 136:
FW: 380200 Community Sup_ervision o
Page 137 and 138:
----_.--_........_.-.._._---------_
Page 139 and 140:
.... #"""" .... 'l~ STATE OF WASHIN
Page 141 and 142:
Distefano. Monica J. (DOC) From: Di
Page 143 and 144:
" \ Prescriber's Name (Print) PreSC
Page 145 and 146:
Nov, 26, 2008 4:39PM CBR Medical In
Page 147 and 148:
,_._ ....... __ .. _._.- - ..... --
Page 149 and 150:
I OFFENDER 1.0. DATA: ..# ....""..'
Page 151 and 152:
Documentation of Medical Authorizat
Page 153 and 154:
Distefano. Monica J. (DOC) From: Se
Page 155 and 156:
11/06/2008 13:05 - PAGE ./"""-1. II
Page 157 and 158:
I:--- j ! -_. Distefano, MonicaJ. (
Page 159 and 160:
Dec .. l0. 2008 1:34PM CBR Medical
Page 161 and 162:
~ec,.10, 2008 1:35PM CBR Med ic"a 1
Page 163 and 164:
Page 165 and 166:
Stern, Marc F. 'Dir Hlth Svc' (~OC)
Page 167 and 168:
!---.-_..- ..._.. _._....__......._
Page 169 and 170:
I J i Date License type: Prescriber
Page 171 and 172:
Distefano, Monica J: (DOC) From: Se
Page 173 and 174:
Page 175 and 176:
I. 1 Distefano, Monica J. (DOC) Fro
Page 177 and 178:
STATE OF WASHINGTON . DEPARTMENT OF
Page 179 and 180:
leT/li od. 8. 200~) 1: 3BAM O/llJVO
Page 181 and 182:
No,7218 pP, 3 , UUj C81'\SS #: lice
Page 183 and 184:
OCT/OS/200S/WED 01:39 PM Tael FAX N
Page 185 and 186:
OCT/08/2008/WED 01: 39 PM Tael FAX
Page 187 and 188:
---------_........_........ .. A i
Page 189 and 190:
.Distefano, Monica J. (DOC) From: S
Page 191 and 192:
~ec. 23. 2UUB 9:U,PM' (;~K Medj'cal
Page 193 and 194:
Dec.23. 2008 5:07PM ,CBR Medical In
Page 195 and 196:
Page 197 and 198:
THCF.MedlcaI ·Clinics· '"9,-J, .
Page 199 and 200:
., FAX No. 509-921-2346 P.' 004 Pr~
Page 201 and 202:
..' ...... M" •••••••
Page 203 and 204:
.. " , Prescriber's Name (Print) Da
Page 205 and 206:
STATE OF WASHINGTON DEPARTMENT-OF C
Page 207 and 208:
. I I 04/15/2009 18: 28 4258595378
Page 209 and 210:
04/15/2009 18:28 4258696378 THCF PA
Page 211 and 212:
Page 213 and 214:
Fax 36027706511· Apr 20 2009 04;31
Page 215 and 216:
Page 217 and 218:
I ' , ..... MARI3DI2009/MON . 09:30
Page 219 and 220:
MAR/30/200S/MON OS :·31 AM FAX No,
Page 221 and 222:
I. STATE OF WASHINGTON DEPARTMENT O
Page 223 and 224:
MAR/18/200S/WED 03:05 PM FAX No, MA
Page 225 and 226:
OFFENDER I.D. DATA: , I . I· .j i
Page 227 and 228:
1 Distefano, Monica J. (DOC) i From
Page 229 and 230:
[,,'B-' 5fi1/#1 '{iYlQ prescriber's
Page 231 and 232:
Distefano, Monica J. (DOC) From: ,
Page 233 and 234:
" \) /"", ·\~\.oyv\~" Or ve,.. l.d
Page 235 and 236:
. I, Offender Name STATE OF WASHING
Page 237 and 238:
:--:7:;'~!;.~:1::7"'!:'·· I i I !
Page 239 and 240:
PDU-6655-3 000236
Page 241 and 242:
5j(B L C W~SEM5 . . ; cm:~EVANS, TR
Page 243 and 244:
_ _ ••• M nr Ln;:,l:.I':.Jl:.
Page 245 and 246:
CBR iviedicai~ inc 3115 E, Mission
Page 247 and 248:
I I J OFFENDER 1.0. DATA: STATE OFW
Page 249 and 250:
Page 251 and 252:
Page 253 and 254:
.------.----:--.-~.- ..-.....__.._.
Page 255 and 256:
·· ! Jan. 23. 2009 11 :49AM CBR M
Page 257 and 258:
clan, 23, 2009 11: SOAM CBR Me~ical
Page 259 and 260:
,_. ! j 1 Distefano, Monica J. (DOC
Page 261 and 262:
63/64/2609 14:08 2654185559 CBR MED
Page 263 and 264:
03/04/2009 14:08 2064186659 CBR MED
Page 265 and 266:
. CBR iViedicai, inc •• 3115 E.
Page 267 and 268:
ST,\T: OF WAS"INGTON DEPARTMENT OF
Page 269 and 270:
3115 E. Mission Ave Spokane, WA 992
Page 271 and 272:
'-"" j ......._.._.......-.- .....-
Page 273 and 274:
Page 275 and 276:
'. : .; ..... '.: ~ ~.;'~". " . OFF
Page 277 and 278:
!. STATE OF WASHINGTON DEPARTMENT O
Page 279 and 280:
".N_ '_'N_' "N /....... . - j .' ,/
Page 281 and 282:
.. Fax CBR Medical, Inc 3115 E. Mis
Page 283 and 284:
J. I OFFENOER 1.0. DATA: , . STATE
Page 285 and 286:
Page 287 and 288:
03/04/2009 14:18 2064186659 CBR MED
Page 289 and 290:
STATEOFWASHINGTON . DEPARTMENT OF C
Page 291 and 292:
t j. 1 l·, r , ! , i ; . 3115 E. M
Page 293 and 294:
Page 295 and 296:
---_._.-» " Distefano, Monica J. (
Page 297 and 298:
STATE O~ WASHItIIGTON DEPARTMENT OF
Page 299 and 300:
...... ,u, .... 1'IL..u.L.\..IHL...
Page 301 and 302:
-- ... --.. _-.- --.---.... J : I .
Page 303 and 304:
,--_._._._.- ...•.._..._...• ,
Page 305 and 306:
I ---~ .......-.- .. ._-_. -.~~- __
Page 307 and 308:
200B-12-16 17:17 • • • • 1.
Page 309 and 310:
•••••••• ~ __ ' •
Page 311 and 312:
j .j I that statement, In conclusio
Page 313 and 314:
Page 315 and 316:
Prescriber's Name (Print) License #
Page 317 and 318:
------·----··-·-···-· .----
Page 319 and 320:
OFFENDER I.D. DATA: STATE OFWASHING
Page 321 and 322:
1813 Born Avenue NE, Suite'#210 Bel
Page 323 and 324: Distefano, Monica J. (DOC) From: Se
Page 325 and 326: Prescriber's Name (Print) Prescripe
Page 329 and 330: 01/21/2008" 20:06 2534724155 VEHICL
Page 331 and 332: #fOr~ . .,;f ~ . {rri'~l STATEOFWAS
Page 333 and 334: 3115 E. Mission Ave . Spokane, WA 9
Page 335 and 336: ·STATE OF WASHINGTOI< DEP.~RTI'iIE
Page 337 and 338: . p(J !/j~1 ·.;IS-.·j / Prescride
Page 339 and 340: ~r.~''''' OFFeNDER 1.0. DATA: ( ~ S
Page 341 and 342: J\' ~ ", < .-, 0 '1...... . -n=:::,
Page 343 and 344: i I Documentation of Medical Author
Page 345 and 346: Distefano. Monica J. (DOC) From: Se
Page 347 and 348: ;lan.14. 2009 9:52PM CBR Medical In
Page 349 and 350: Jan, 14, 2009 9:53PM CBR Medical In
Page 351 and 352: Ja n,. 14,2009 9:54PM CBR Med i ca
Page 353 and 354: STATE OF WASHINGTON DEPARTMENT OF C
Page 355 and 356: 3115 E. Mission Ave Spokane, WA 992
Page 357 and 358: 3115 E. Mission Ave Spokcme, WA 992
Page 359 and 360: OFFENDGR I,D, DATA: STATE OF WASHIN
Page 361 and 362: .IL , Documentation of Medical Auth
Page 363 and 364: J STATE OF WASHINGTON DEPARTMENT OF
Page 365 and 366: 3115 E. Mission Ave 'Spokane, WA 99
Page 367 and 368: OFFENDER 1.0. OA·I.o.: STATE OF WA
Page 369 and 370: STATE OF WASHINGTON DEPARTMENT OF C
Page 371 and 372: MARIJUANA MEDICINE- EVAlUATtON CENT
Page 373: ~flor~1I .J''; ~. I l ~ATE OF WASHI
Page 377 and 378: GBN Medical lnc, No, 2826 p, 1/20 I
Page 379 and 380: 1-------' J Dec.23. 2008 5: 24PM CB
Page 381 and 382: Uec .. LJ. 2UUB ~:2!JPM No. 2826 P.
Page 383 and 384: March 23, 2009 STATE OF. WASHINGTON
Page 385 and 386: t. Page 1 ofl ..,,-;...-.... -. ...
Page 387 and 388: 'I ! I i Prescriber's N~rint) , Lic
Page 389 and 390: · I, Karen Hamilton, am a physiCia
Page 391 and 392: Distefano, Monica J. (DOC) From: Ha
Page 393 and 394: OFFENDER 1.0. DATA: STATE OF WASHIN
Page 397 and 398: Page 1 of3 Distefano, Monica J. (CO
Page 399 and 400: Page 3 of3 To: Checo, Ana V. (DOC),
Page 401 and 402: PageZ of3 . 253-372-6463 office 253
Page 403 and 404: Jan. ::lU. :.1UU9 1 L: U~PM ~cott L
Page 405 and 406: OFFENDER 1.0. DATA: STATE OFWASHING
Page 407 and 408: Scott L. Havsy, DO, DAApM -Board Ce
Page 415 and 416: I Prescriber's Name (Print) License
Page 417 and 418: Living &: WeUness Centerss P.S. 371
Page 419 and 420: FEB-18-2009 14:56 From: To: 360 586
Page 421 and 422: M •••• M •• __ • ___
Page 423 and 424: STAT!: OF WASHING"ON DEPART1\lIENT
Page 425 and 426:
Dec. 12. 200 8 4 : 03 PM C B R Md i
Page 427 and 428:
Dec. 12. 2008 4:04PM I CBR Medical
Page 429 and 430:
. Nov. 2~. 2008 3: 05PM CBR Medical
Page 431 and 432:
"NOV-12-2008 WED 01~45 PM SPOKANE'N
Page 433 and 434:
j " 'NO~:12-2008 WEO 01:44 Pi SPOKA
Page 435 and 436:
"NOV-12-200B wED 01:45 PM 08/'~/lOD
Page 437 and 438:
Page 439 and 440:
·I~I La Crmica tid Carifio ~':./ .
Page 441 and 442:
UCT/l~/ZUUH/WKU Ul:l1 PM Due WE:;)'
Page 443 and 444:
(;tlKlVledlcalln·c, (. I~o, LtlL/
Page 445 and 446:
Dec.23. 2008 ,:31PM GSg Medical Inc
Page 447 and 448:
Dec, 23, 2008 5: 32PM CBR Med i ca
Page 449 and 450:
CO (') -K~ . C c..l)' ,_ .,..,. ADD
Page 451 and 452:
I ,[ .l. L I : I I" i pec. J. 2UUB
Page 453 and 454:
Dec.23. 2008 4:41PM CBR Medical Inc
Page 455 and 456:
Dec.23. 2008 4: 42PM CBR M~dical In
Page 457 and 458:
D.ec.23. 2008 4:43PM CBR Medical In
Page 459 and 460:
Dec.23. 2008 4: 49PM C B'R ·M.e di
Page 461 and 462:
Dec, 23, 2008 4: 50PM CBR Medical I
Page 463 and 464:
Page 465 and 466:
I I , Smith, Sherri K. (DOC) From:
Page 467 and 468:
~- 6S/2e/26ee 12:ae 2538475797 PAGE
Page 469 and 470:
February 17, 2009 STATE OF WASHINGT
Page 471 and 472:
Jan. 4. 200912:40PM CBR Medical Inc
Page 473 and 474:
Jan, 4, 2009 12:41PM CBR Medical In
Page 475 and 476:
Dec.30. 2008 12:20PM CBR Medical In
Page 477 and 478:
Page 479 and 480:
Nov.2[ 2008 '4:52P~ CBR Medical Inc
Page 481 and 482:
j i ! I Naif. 26. 2008' 4: 51 PM CB
Page 483 and 484:
Page 485 and 486:
.' :r Jan. ~ 2009 12:39PM C B R Me
Page 487 and 488:
Jan. 4. 2009 12:40PM CBR Medical In
Page 489 and 490:
Page 491 and 492:
Page 493 and 494:
(i &1 . OEPARTM"ri;;.toF·COruu:CTI
Page 495:
show all

DOC request three complete - Cannabis Defense Coalition

Create successful ePaper yourself

Delete template?

Save as template?