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Dec, 23, 200B ~: 31PM CBK Med i ca I Inc, No,2B21 p, 2/36 STATE OF' WASHINGTON OEPARTilliENT OF CORREctioNS AUTHORIZATION FOR DISCLOSURE TH INFORMATION OI'r-CNOER 1.0. OI\TI\: hereby authorize the use or disclosure of my health information organizatiori is authorized to make the disclosure: "'M"" C 'b h J. f. i , . t1 ''-j"'' ''''' 0:;. "t\ "'_. J~tLC-l " C .. ··· ... ·, .....!-,·h. C ADDRESS: "'6 I \ ":J ·t::;,.--'--o,-
Dec.23. 2008 ,:31PM GSg Medical Inc. No. 2821 P. 3/36 ..;I' .... ' .. ''''~~ , ( . l' STATEOf'WASHINGTON DSPARTMENT Of COr:!REcnONS . Medicinal Use of Marijuana Verification OIH:NnFR 1.0. DATA: Dear prescriber, By stete statute the Washington State Department of Corrections is charged With the responsibility to supervise some offenders after they have been convicted .of a felony. 'The above named pati~nt ilii. currently under supervision by the Pepartment. Supervision is designed to help the offender avoid those environments or situations ·that lead to their criminal behavior. Often illicit drug use is a contributing factor. in an individual's criminality. Accordingly it's U5uatthat the court or the Department of Corrections will impose a condition of supervision that the c,ffender not use, or possess illicit drugs, including marijuana. This offender has claimed that they have a condition Tor which the medicinal use of manjuana has . been recommended, the belOW verification is·to determine the legitimacy of their claim. Thank you in advance for your· assistance~ If you have questions please teel free to personally contact the Medical Director of the Department at (360) 725-8700. . . . 1. Is this patient under your care ~ D No 2. Are y~u recommending medical marijuana for his patient due to a diagnosis of Acquired Immunodeficiency Syndrome (AIDS) a, If the answer to question 2 is ·Yes·, does he/she have anorexia b. If the answer to que~tion 2a is "Yes',~oes he/stie have weightloss 3. Are you re~mmending medical marijuana for this patient due to nausea and vomiting associated with cancer chemothe~py . . " a. If the answer to question 3 is "Yes", has the patient failed to respond to conventional antiemetic treatments· ... /11+- DYes . g-~ . rv(r'7 Ol->,''''''',,'''s -4.d-No Nff* D ¥es rj-No DYes QVes h. If the answer to question 3a is "Yes", please describe what those treatments were (medication, dose, . duration): . . [rNc:· fiNo 4. c. Whatis th·e planned schedule O{Chemoth~h . If you answered "No" to items 2 & 3 above, wh~t is the reason you are recommending piedidnal use of marIJuana. . e.:.. (" "'.. I>.,.,-'\...~" '~ . " . . J \, a. Please provide evidence pUblished in a peer-reviewed SCientific publication to support the medicinal. use of marijuaWil for this purpose' S· \-\--t ~ \...~ .1'\' . . ____ -:-___ ---:.. __________ ~ ~ r-., ~~. .' {~ '~------~--------------~---- 5. 6. While on community supervision ("parole") tile Department of Corrections o~IY aut~oriz7s the use of the oral synthetic formulation of marIjuana. If the Department authOrizes thiS patlenrs use of rnedir,al marijuana, will you be prescribing only the oral synthetic formulation The patient's accompanying Release of Information authoriZes you to provide the . Departn'ient with current and future inform;ation related to this [ssue. Do ~ou agree to notify the Department's Medical Director of any changes in your ansW(3rs above· O· Yes 0 Yes lJOC 14-053 (Rev. 7J31/0S) J:lOC·3BO.200 ."1; . PDU-6655-3 000442
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STATE OF WASHINGTON DEPARTMENT OF C
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RECORDS PROVIDED WITH REDACTIONS ~~
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i ( Documentation of Physician Auth
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eRR Medical, Il1c 3115 E. Mission A
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Or-FENDER 1.0. DATA, j' STATE OF WA
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Chapter 69.51 A RCW: Medical marij1
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Interpretation of Medical Marijuana
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Date & Tirpe Created: 12/16/2008 11
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