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Dec,23. 2008 4:41PM CBR Medical Inc, No, 2824 . p, 2/28 . S'rATr;; OF WASHINGTON DEPAATMENTOF CORRecTIONs ,AUTHORIZATION ~::OR DlSCLOSURr~ OF HEALTH INFORMATJOfll NAIVIE:: . ADDRESS: hereby author~e the use or disclosllre of my health information . organiza~ion is authori;zed to maKe the disclosure: (:. :) ..: I' ,..l.-i" j . _ / \ ~ I_I ;f.... _.. ,iI" !~ I. t: t. v ~ .... t" • ·'''::~fi \ .J-;'" t.· d' ;~"l:[i·~::.::~~:~:;:;.-~)rJ/{~ .---.::,/ ') ,> ~ .. t·:·t ' : I. ..,fz..,.••/". '" LL).. ~'., ' . .!,".i.:
Dec.23. 2008 4: 42PM CBR M~dical Inc. No. 2824 P. 3/28 .... ' '0' "'" . . nFFtNoernu. ,',p,J"A' ~d)' ~ I;' . r iiOI.· STA"F.! OFWASHliI!GTON DEf"AR1'iI'lEN'r OF CORREc;TIONS Medicil'lJaH Use of Mar~ilLlal1l;a VeJl'Ufica1tiot1l --.. ,,- lIfIa·_-;·;· .. ~~ --'I .. -----.- )-.~ ... To be I'llled out by PrEls(~riber: Dear Prescriber, By state statLite the Washington state .Department of Cqrrections is charged i.vith the responsibility to supervise some offenders. after' they have been aonvicted of a felony. The above named patient is cllrrently {Jl'ider supervisi(jr\'by the Department Supervision is designed to ilelp the offender avoid those environments or situatiolls that lead to tl)eir criminal behavior. Often illicit drug use is a contributing factor in an individual's criminality. Accordingly it's usual that the court Or the Department of Corrections will impose a condition of supervision that the offender not use, or possess iilicit drugs, . including marijuana. This offender has claimed that they have a.condition for which the ,medicinal use of marijuana has been recommended, The belOW verification is to determine the legitimacy of theJr claim. Thank. you in advance for your assistance_ If you have questions please feel free to personally contact the Medical.Director of the Departmentat (360) 7,5-8700. , . 1. 2, 3, Is this piltient under your care Are you recommending medical marijuana for his patient due to a diagnosis of Acquired Immunodeficiency Syndrome (AIDS) a. If the answer-to question 21s "Yes", does helshe haVl1l ,anorexia b" If the answer to queslion 2a is "Yes"; does 'helshe Ilave weight loss' Are you recommending medical marijuana for this patient due to nausea and vomiting associated with cancer chemotherapy a. If tl:e an~wer to question 3 is ;'Yes", ha.s the patient failed to respond to conventiona~. (r. antiemetiC treatments . . - II/,J DYes ~rN~~ !.;l~ 1a~Y-arN.~"f.1·'No /iin [lXgs.--·-8-NQ DYes . ".." la'No .J c. 4. ',.' 1\ \. ", ~"I"... ""''::;~):"""" ________---'_--"":___--'-_ 5. While on community supervision ("parole") the Department of Corrections only authorizes the use of the oroll synthetic formulation of marijuana. If the Department ~l,lthorizes ~hiS patient's' 0 Yes use of medical marijuana, will you be prescribing ol11y the oral synthetic formulation 6_ . The patient's accompanying Release of Info.rmation authori~e~ you to provide the _ {)epaltment with current and future info(mation related to thiS Issue. Do you agree.to notify the Department's Medical Director of any challge~ in your answers above . DYes Q-NO'" .... - 01\lo <strong>DOC</strong> 14-0~:i (Rev. 713"1/08) OOC.3BO.200 PDU-6655-3 000452
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STATE OF WASHINGTON DEPARTMENT OF C
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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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. ! STATE OF WASHINGTON DEPARTMENT
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STATE OF WASHINGTON .DEPARTMENT OF
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OFFENDER 1.0. DATA: STATE OF WASHIN
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