DOC request three complete - Cannabis Defense Coalition

Dec. 23. 2008 4:42PM CBRMedical Inc.
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License#:
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PreSClib€r's. Signli'ture
License type:
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Prescriber's Address :;; U.~~~::_. t·. . /l:'{ .~~ :'j / ,~_.~4.. \..'f Phone Number·
Prescriber: please l'etll~~;'ii~'~~t~~~h~~~e p;t~~rii'~ ;2;~1~~fh~~'ormat,on to:
No. 2$24 . P. 4/28
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Mediqal Director .
Health Services Division
Washington State D~partment of .Corrections
PO Box 41'li3
Olympia, WA98504·2113
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·ro be filled out by DOC Physician:
I have reviewed this verification form and find that use of medical marijuana by'this patient'
. (check one) .! 0 is D is not .'. .
consistent with DOC Policy. . ..
Physician's Signat\li~ • ':-. ---..... --_... .-
Date'
. Instructions to DOC Physician:
When form is complete:
1. . Email your finding above to the Assistant SSGretaryfor Comlllunity Corrections
2. File this forrnand the i:\ccompanylng Release of [nformation hi Liberty as a'Community Corrections Health Recqrd ..
Stl!tc law (RCW 70.02; RCW 70.24.1 05; RCW 11.06.390) and/Qr fadorai regulatiorn;. (41 CFR part 2; .45 CFR I"art 164) prohIbit
disclosure of tlll!llnT'lrm