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J Dec,23. 2008 4:48PM CBR Medical I . n c, No, 2823 p, 1128 !Fax .. 3115 E. Mission Ave Spokane, WA99202 i. , 'Comment:!>; tl ,., ..., n nlnnt','\ ..... "'-nhr' n Pll'tl'lliF. RICVGI, ._---.--'--'- /. "' 'CBR MedIcal, Inc. - ·3115 E. MIssIon Ave, Spokane, Wa 9920;2 Seal tIe Phone 206:..774-6493 Fax 206-418-6659 Spokane Phone 509-2,1\·2·8624 F:..x, 509-340-2710 ,Tri-Citlt:i6 Phone 509-416-2267 Fax 509·3J\0-2710 Vancowor Phone 3[30-635-6484 1= ax 206-4 '113-6659 CONFID~NT1AI .. ITY NOTICE: 'This communication is intended for the sole lIse.tJf the Indivldual and entity to whom it is r~ddre5sed, and may contain· information that is privileged. or cnnfidential and exempt from disclosure under applicable law, You are hereby notified th6\t any disseminaiion, . distribution, or ctupficatlon of thi clJlTIffiunication by someone. oti1er than the intended' addressee or its designated "gent is strictly prahibtted. . Allll1formation is flrotected Under U.S. Fl;lderal Law PDU~6655-3 000455
Dec.23. 2008 4: 49PM C B'R ·M.e die a 1 Inc. No. 2823 P. 2/28 OFFF.NCER ID. OATil: STAT~ OF WASHINGTON DEPARTMENT OF CORRECTIONS Medicinal Use of Marijuan2 Verification TO be filled out by Prescriber: :,. __ ... 1~~ F"® __ I Dear Prescriber, . t:ly Stale staIUte me VV nntl;rt'Il"ln'll'lntr nr ritll.,tinnr th..,t lQ'l1ri In thi-ir f'rimin'iill· 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 illicit drugs, including marijuana. This offender has .claimed that they nave a condition for which the medicinal use of marijuaria has been recommended: The below verification is to determine the legitimacy of their Claim. Thank you in advi;lnce for your l. 725-8700. . . ~' 1. Is this pati~n~ under your care Q Yes D No ~. p.re you reCOlllrrll:lIIlJIIIY IIIt:I./fI,:CllllldiljudIlCirul !rio !o'",lic,·.LdLc6 t.::." dingl'l~:5i~ ofAoql.1!rod Immunodeficiency Syndrome (AIDS) a. If the answer to' question 2 is "Yes", does he/she have anorexia r-tlf~ b. . If the answer to question ~a is .IIYes". does' he/she have w!;liylrllu~~tl/.r.;· 3. Are you recommending medical marijuana for this patient due to nausea and vomiting associated with cancer chemotherapy UYes [3~-nNO Q.¥-e9'-~·"·B .. No DYes a. If the answer to question 3 is "Yes", has the patlent failed to respond to conventional antiemetic treatments #/A-. .. . . ! b. If thf'l AnRWAr to !1u('::;;tion 3a is ·YeS". pl~ase describe what those treatments were (medication, dose, . duration): .. . ,if A- . .'. . c. What is the Plan~ed .schedule of chemotherapy IV I Pr ~. . . 4. . I:J. 6. a.' . If y~~ ans~ered "No" to items 2 &. ~~. bove, whatis th~ reason you are recommending medicinal u~e of marIjuana.· ,,~ e . '" ~ . ~ "h.t ~ . . . '- "- • or-..... ~. • .c;... . t'l~Cl::,t:: fJ1\,JVIUC CYIUt;;I,'¥t;:i tJULJ"""II""'" J. l ..... !'IV~' 1_.1_ •• :... .... __ :_ •. cri_ r ... 1.1" .•• : ... 10 ... _ •• ,.. ....... fh,.. n'l1'IaI'Iir'\innll rrn "f marijuana. for this purpose ( ~. . \ • (\ .' . r j~-~. ~c;.,.",~-~ YYT1JI6 on COmfflI,JIIIlY :101.11-'1;:1 Vh:lIUIl \ ).I", ..... '" J L"'" ...... J-' .. d", ..... ~ -P "'--: •• _..:~t_ .. _. ':"', ..• ~. ~-1-7- " ... use ofthe oral synthetic formulation of marijuana. lfthe Department authorizes thiS patlent·s . 0 Yes use of medical marijuana. will you be prescribing only the oral synthetic fcrmul.ation The patient's accompanying Releas~ Of Info.rmation authOfi 7es you to provide the . . Department with current and future mformatton related to thIS Issue. Do you agree. to notify rhn nnn'irtmQnt'li Mli'lriiral nifFr.tnr of nnv r.himQ~~ in Y9ur answers above DYes / [No· UOG 14·053 (Rev. 7131/06) <strong>DOC</strong> 380.200 PDU-6655-3000456
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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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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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j I Documentation of MedicarAuthcir
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Chapter 69.51 A RCW: Medical marij1
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OFFENDER 1.0. DATA: STATE OF WASHIN
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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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I I do ncit want to ruffle feathers
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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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E.... KIOSK reporting may be used i
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Dec .. l0. 2008 1:34PM CBR Medical
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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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J STATE OF WASHINGTON DEPARTMENT OF
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3115 E. Mission Ave 'Spokane, WA 99
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· I, Karen Hamilton, am a physiCia
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Distefano, Monica J. (DOC) From: Ha
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OFFENDER 1.0. DATA: STATE OF WASHIN
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Page 3 of3 To: Checo, Ana V. (DOC),
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OFFENDER 1.0. DATA: STATE OFWASHING
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