DOC request three complete - Cannabis Defense Coalition

'.Vec,LJ, 2UUH ~:2JPM CBK Medical lnc, No, 2826· p, 4/20
STATE OF WASHINGTON
DEPAR11IIENT OF CORREC,.loNS
AUTHORIZATION FOR DISCLOSURe
OF HI;l:ALTH INFORMATION
OF!'eNOER 1.0. CATA:
I, , hereby authorize the use or disclosure of my health information
as described below. The following individual or organiZatlon is authorized to make the disclosure:
NAME: ______ _
ADDRESS:' _______ ...___._____ ~ __
The type and date(s) of informi;ltion to be used' or disclosed is as follows:
-----.. ,-----:---
Purpose for dlscfosure:. __ _
------.... _-----
I unde:rstandthat the infoimation in my health record may include information retating to sexually transmitted
infections, Acquired Immunodeficiency syndrome (AIDS), or Human Immun()defil~lency Virus (HIV). It may also
include informationabou~ benavioral or mental health '. , • , • • • •• ., •
This information may be disclosed to and used by the
NAME: ~ _________ _
ADDRl=SS: __ ~ ___ _
--_._,,----
! understand that I have a right to revoke this authoriz;
authorization I must dO so in writing and present my w
Department I undermand that the revocation will not
response to this authorization. Unless otherwise revo
or condition:
...._ CIf I
I understand that authori.:ing the disClosure of this he<
authOrization. I need not sign thi!O form'in order to as.
information to be m;ed or'disclosed, as provided in Cf
of infOrmation carries With it the potentiql for an unautl
state confidentiality rules. If I have questions about oi
l/J ,~,Wf.i(
/J h t>s~~«
1- . -}./
D ,..', c.: -rr
RHIT/designee oftha facility: _____ ~ ___ ._---,-___ ~ __
.. ";'
, . ~;
nent
lin
ate, event,
)m signing).
s
opy the
disclosure
Idarslor
, Signature of paUen!
(Do not sign Iffonn is not completo)
-_.,---
Date
(Petfent 1tl complete)
SocialSecurlly Number Oats ofBirih
-~----
DOC Numbllr
-~,.----
. Signature OfWilnoss ]').. 1 ..
Slate law (Rew 70.02; RCW 7Q.24. W;; RCW 71.0S.J9Q)