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OCT/22lZ00S/WED 02:27 PM DOG WEST V,~I{ f) .. FAX No. 36057660.09 ,r' 0, I \ t. P. 003 < ......,,"..,.~ .1Jll& DEPARTMENT f ~ 'J 'STATE OF WASHINGTON OF CORRECTIONS Medicinal Use .of Marijuana Verification OFFeNO~R 1.0. OATA; Dear Prescriber, By state statute the Washington State Department of Corrections is charged with the responsibility to supervise some offenders after they h~ve been convicted of a felony. The above named patient Is currently under supervision by the Department. Supervision is designed to help the offender avoid those environments or situations that lead to their crirl)lnal , behavior. Often Hllcit dn-!g use Is a contributing factor in an individual's criminality .. Accordingly It's usual that the court or tha Department of Corrections will impose a condition of supervision that the offender not use, or possess illicit drugs, . inclu'ding marijuana. This offender has claimed ih
UCT/l~/ZUUH/WKU Ul:l1 PM Due WE:;)']' VAN. () HX No, :JtiU~'/titiUU~ . '_ ..... , p, UU4 Prescriber: please r.eturn this form and the patient's 'Release of Information to: Medical Director Health Services Division Washington Sta.te Department ofCoIl'ecnOns PO Box 41123 Olympia, WA 98504-2113 To be filled out by DOC Physician: Physician's Name (Print) Physldan's Signature Date Instructions to DOC Physician: When form Is complete: 1. ' Emaii your finding above to the Assistant Se'cretary for Community Corrections . 2.· File this form and the accompanying Release of Information In LIberty as a CommunIty Corrections Health Record. Srare law (ReW-70.02: !
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STATE OF WASHINGTON DEPARTMENT OF C
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RECORDS PROVIDED WITH REDACTIONS ~~
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(".- " ~"""'":.~ Inr ... ~ STATEOFW
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i ( Documentation of Physician Auth
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OCT/ Oct. B. LUO~, 11: ::J9AM T ~co
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... ""'"'''' f~ STATEOFWA$HINGTON ~
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Distefano, Monica J. (DOC) From: Se
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eRR Medical, Il1c 3115 E. Mission A
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Fax : ' 3115,E. Mission Ave Spokane
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Or-FENDER 1.0. DATA, j' STATE OF WA
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DoCumentation of Medical AuthoriZat
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STATE OF WASHINGTON DEPA'RTMENTOF C
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311S'E. Mission Ave Spokane, WA 992
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j I Documentation of MedicarAuthcir
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Chapter 69.51 A RCW: Medical marij1
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Chapter 69.S1A RCW: Medical marijua
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Chapter 69.511). RCW: Medical111ari
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OFFENDER 1.0. DATA: STATE OF WASHIN
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Prescriber's Name (Print) License#:
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3115 E. Mission Ave Spokane, WA 992
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. ! STATE OF WASHINGTON DEPARTMENT
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STATE OF WASHINGTON .DEPARTMENT OF
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T.)' ~x.. MARIJUANA MEDICINE'· 'EV
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Wheeler, Judine L. (DOC) From: Sent
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OMNI: Chrollos Quick Search , •
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-...... THCF MEDICAL CLINICS 1813 1
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Prescdbar's Name (pnnt) . Prasc~jje
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I I do ncit want to ruffle feathers
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Let me know if you have questions f
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Interpretation of Medical Marijuana
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From: Sent: To: Duggan, Brenda J. (
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NIELSEN TO COME UPSTAIRS. CCO NIELS
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Date & Tirpe Created: 12/16/2008 11
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PRIMARY CARE PHYSICIAN AND LOOKED O
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Distefano, Monica J; (DOC) From: Se
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3. High Non-Violent 4. Moderate, an
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, ' ~. With Community Corrections S
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I FW: 380200 Community Supervision
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Distefano, Moriica J. (DOC) From: .
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E.... KIOSK reporting may be used i
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RE: 380 200 Community Supervision o
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RE: 380200 Community Supervision of
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to be processed now. If this was re
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FW: 380200 Community Supervision of
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Distefano. Monica J. (DOC) From: Di
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Documentation of Medical Authorizat
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Distefano. Monica J. (DOC) From: Se
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11/06/2008 13:05 - PAGE ./"""-1. II
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Stern, Marc F. 'Dir Hlth Svc' (~OC)
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I J i Date License type: Prescriber
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Distefano, Monica J: (DOC) From: Se
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STATE OF WASHINGTON . DEPARTMENT OF
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OFFENDER I.D. DATA: STATE OFWASHING
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1813 Born Avenue NE, Suite'#210 Bel
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Distefano. Monica J. (DOC) From: Se
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3115 E. Mission Ave Spokcme, WA 992
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OFFENDGR I,D, DATA: STATE OF WASHIN
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.IL , Documentation of Medical Auth
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J STATE OF WASHINGTON DEPARTMENT OF
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3115 E. Mission Ave 'Spokane, WA 99
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OFFENDER 1.0. OA·I.o.: STATE OF WA
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MARIJUANA MEDICINE- EVAlUATtON CENT
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Page 405 and 406: OFFENDER 1.0. DATA: STATE OFWASHING
Page 407 and 408: Scott L. Havsy, DO, DAApM -Board Ce
Page 411 and 412: Distefano, Monica J. (DOC) From: Se
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Page 465 and 466: I I , Smith, Sherri K. (DOC) From:
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