DOC request three complete - Cannabis Defense Coalition

"NOV-12-200B wED 01:45 PM
08/'~/lOD~ lu:44 ~AX bU~~qvlrlu
SPOKANE NBS UNIT
FAX No, 509-482-3853 p, 003
~VVI/VV\J
OFFE.'IC=." I,D, DATA:
\ '
STATIO 0/= WASHINGTON
CEPARTMENTOF COltRS0110NS
AUTHORIZATION FOR DISCLOSURE
OF HEALTH INFO~MATION
I. ...... L~ ___________"
hereby authorize the use or disolosure of my 'health information
!IS desc(lbed belew, The following IndIvidual or organlzatlon Ie authQrized tQ m!!!ke the disclosure;
, NAME:' 66 e.. MM; c;"'r
ADDRESS: -;s \ 15 p.. A . ssi Q Q '8 J e
~b¥.P't'U' IV ~ 9 q "2..0 ~
.
The type and date(s)of informatlOIl to be used or disclosed is i*l follows:
M.~ i c:-l.
~tf~;;r~~,~o,~; ~J,~1;;;:4:
PtJrposefor dl$oI06UI'e! V -€ V--;, C'y ; ~3 lMe J~~.( VU 4 C -'J ,.113 "" 4, eO OJ' row bdi:b~ rt
I understand that the Information in my health reoord may include Information relating to sexually transmitted
infections, AcquIred Immunodeficiency Syndrome (AIDS), or HUman Immunodeficiency Viruili (HIV). It may also
Incll,lde information apout b~havlotal or'mental health services and treatmelltfor alcohol and drug abuse.
This Information may be disclosed to ;and used ~y the following Individual or organization: .
NAME: Scott Wright
ADDRESS; 630 W. Shanno(J
Spokilns, WA
99205
I understand that I have a right to revoke this authorlzetloo st any Ume. 1 understand that If I revoke this
authorization I must do so In writing and present my written revocation to the Health Information Management
Department. I understand that the revocation will not apply to Infornllii![on that has already been released in
resllonse to this authoilzation. Unless oth9:1.ise/evoked. thi!! autiioriza:ion will expire on the followlog eate, eveot,
,or condition: 8Q'1$!f"'7tbQwe"'~f rDF~'f left blank, aut"Ioriza!loil w!1I eXflire sIx (6) months from signIng).
I understand that authorizing the disclosure of this health Information Is voluntery. ~ can refuse to sign this .
authorization. I need not sign ,thls'form in Qrd~to assure treatment. II.mderstand that I may iMpect or copy the
information to be usee' or disclosed, as providid in CFR 164.524 alld RCW 7Q.02. I understand Ih