DOC request three complete - Cannabis Defense Coalition

-.." 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.