DOC request three complete - Cannabis Defense Coalition

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Prescriber's N~rint) ,
License #: to 1 ~ - I \ 3 (0 0 ~ LiceRse type: NP I
Prescriber's Address
Phone Number
Prescriber: please return this form and the patient's Release of Information to:'
iv1edicai Director
Health Services Division
Washington State Department of Corrections
POBox 41123
Olympia, WA 98504-2113 '
001 Mar Community IIealth Centers
~, White Center Medica!
,~=, 9650 J5lli Ave &W #100
'ii' &ea.ttle, WA 981C6
('2C6) 965 10c0 Vax it ~) 9ffj 1001
To be filled out by DOC Physicictn:
I have reviewed this verification form and find that use of medical marijuana by this patient
(check one) I Dis 0 is not '
consistent with DOC Policy.,
Physician's Name (Print) Physician's Signature Date
Instructions to DOC Physician:
When form is complete:
1. Email your finding above to the Assis~ant Secretary for Community Corrections
2, File this f~rm and the accompanying Release of Information in Liberty asa Community Corrections Health Record.
State law (RCW 70.02; 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
permitted by law.
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DOC 14-053 (Rev, 7/31/08) DOC 380,200 &3
PDU-6655-3 000384